t an academic medical institution in Baltimore, several doctors examined a teenager. They were mystified by his rapid weight loss, an unusual and alarming condition for an otherwise healthy young man. As the boy shivered on the exam table, his doctors mulled which blood tests to order, metabolic tests to run, and potential diagnoses. A volunteer member of the primary care clinic’s extended care team wondered aloud, “Do you think he’s hungry?” One of the doctors replied, “He’s never said anything like that, but you can ask him if you want.” It turned out that the teen had recently moved out of his home, often didn’t have enough money to buy food, and simply went without.

Variations of this story play out across the country hundreds of times every day. Unmet social needs represent a disastrously overlooked, or ignored, underpinning of poor health, disability, and even death.

Expanding “comorbidity”

Doctors use the term comorbidity to describe the simultaneous presence of two or more chronic diseases or conditions in a patient. They readily include in this category high blood pressure, diabetes, obesity, depression, and others. It’s high time to include in the definition things like the inability to get enough food, not being able to refrigerate insulin because the electricity got shut off, not having safe and secure housing, and the like.


A recent study conducted by researchers at Massachusetts General Hospital, in conjunction with my company, Health Leads, affirmed that social comorbidities are an inescapable reality of patients’ lives. Likewise, they should be an inescapable reality of the business of health care. We found that unmet social needs are associated with:

  • nearly twice the rate of depression
  • 60 percent higher prevalence of diabetes
  • more than 50 percent higher prevalence of high cholesterol and elevated hemoglobin A1c, a signal of diabetes
  • more than double the rate of emergency department visits, and
  • more than double the rate of no-shows to clinic appointments.

Today, it’s widely recognized that just 10 percent of health outcomes are attributable to medical care, while 70 percent are tied to social and environmental factors. Given those numbers, you’d think that leaders in the health care industry would roll up their sleeves to get to the bottom of this problem, or at least establish payer-provider partnerships to better manage these social comorbidities through incentives.

I’m not an economist. But I find it hard to imagine that we can achieve sustainable health reform if we ignore 70 percent of what’s driving health outcomes and costs. Yet if you look at spending in the health care sector, little funding is devoted to identifying or addressing unmet social needs.

Changing what counts as health care

Today we spend most of our time and money wrangling about clinical care, while population health — the health outcomes of groups of individuals — has been allowed to languish. We need to blur the distinction between clinical care and population health and look more closely at unmet social needs.

Here are three things the health care sector can do to address unmet social needs.

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Understand patients’ needs. We collect an immense amount of data on our patients, yet we fly blind when it comes to their social needs. How complicated would it be to ask about just five social needs — food security, housing, utilities, transportation, and domestic violence — on patient intake, health risk, or needs assessments questionnaires? This information could identify in real time which patients have unmet social needs affecting their health. As health systems implement strategies to effectively address these needs, we can know which patients actually secured healthy food or got their electricity turned on, and begin to triangulate social needs information with claims, outcomes, and utilization data.

Bring payers into the mix. Provider organizations have long taken the lead on social needs in health care, but they can’t systematically address unmet social needs without the help of payers. By measuring providers’ success in addressing their patients’ social needs and incorporating that information into incentives, payers could definitely move the needle. For example, they could reward a clinician who helps a patient and her family get food, and not reward one who gives a patient an outdated list of food pantries and leaves it to her to negotiate all the language, transportation, and bureaucratic obstacles to actually getting the food she needs. Moreover, payers themselves — who collect enormous amounts of data through health risk appraisals — must begin asking their members about unmet social needs if they truly want to improve the health of the people they cover.

Incorporate social needs into technology platforms. We don’t have broad data on patients’ social needs because we don’t routinely collect it. We must build social needs questions and workflows into our electronic health and medical technology systems. Developing a small set of standard social needs questions would make possible meaningful comparisons across different health systems, service areas, and geographies.

Health reform is built largely on the promise of person-centered, compassionate, and equitable care, but without addressing social needs it’s an empty promise. Making it full and real is within reach by making access to social and other nonmedical resources a standard part of quality health care. We don’t need a single new invention or breakthrough — we simply need leaders with the courage to deliver the type of health system we all say we want.

Rocco Perla is president of Health Leads, a Boston-based company focused on addressing patients’ basic resources as a standard part of quality health care.

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