Unmet Patient Psychosocial Needs in American Healthcare: The Case for Integrating Behavioral Health, Social Services, and Primary Care

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Discussing the Causes Of Unmet Patient Psychosocial Needs

Lack of Funding for Social Determinants

Social determinants of health as outlined by The CDC (2014),

Factors that contribute to a person's current state of health. These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature. Scientists generally recognize five determinants of health of a population:

Biology and genetics. Examples: sex and age

Individual behavior. Examples: alcohol use, injection drug use (needles), unprotected sex, and smoking

Social environment. Examples: discrimination, income, and gender

Physical environment. Examples: where a person lives and crowding conditions

Health services. Examples: Access to quality health care and having or not having health insurance. (para. 4)

[pic 2]

Figure 2. Determinants of Health. Reprinted

from Creating Health Equity in Minnesota, by Minnesota Department of Health, 2016, Retrieved

from http://www.health.state.mn.us/divs/che/creatinghealthequity.html

According to Davis, Stremikis, Squires, and Shoen (2014), the United States of America has the most expensive health care system in the world but the U.S. has consistently placed last, based on most dimensions of performance and health outcomes of the 11 countries studied in their 2014 report: Australia; Canada; France; Germany; New Zealand; Norway; Sweden; Switzerland; the Netherlands; the United Kingdom, and the United States. Bradley and Taylor (2013) stated, “Per capita, the United States spends nearly double what some of its peers spend, but Americans lag behind in terms of life expectancy, infant mortality, low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted diseases, HIV/AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability rates” (pp.181-186). Bradley and Taylor attributed this disparity to the ratio of health care spending versus social services spending. “Although overall spending on social services and health care in the United States is comparable to other Western countries, the United States disproportionately spends less on social services and more on health care” (Bradley & Taylor, 2013, pp.181-186).

Health Care Spending as a Percentage of GDP, 1980-2013

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Figure 3. Healthcare Spending. Reprinted from U.S. Health Care from a Global Perspective, by The Common Wealth Fund, 2015, retrieved from http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

According to the Centers for Medicare & Medicaid Services (2014), the U.S. national health expenditure “grew 5.3% to $3.0 trillion in 2014, or $9,523 per person, and accounted for 17.5% of Gross Domestic Product (GDP)” (NHE fact sheet). Bradley and Taylor (2013) found that the U.S. spent the least on social services at just 9 percent of GDP. Moreover, the study found America spent less than sixty cents on social services to every dollar spent on healthcare while eleven countries that are a part of the Organization for Economic Cooperation and development (OECD) spent roughly two to one on social services versus health care (pp.181-186).

This oversight in spending has neglected to address a crucial piece of community health, making the U.S. ineffective at providing services to prevent common diseases and injuries.

McGinnis and Foege (1993) explained,

Because most diseases or injuries are multifactorial in nature, a key challenge is sorting out the relative contributions of the various factors. For heart disease, well-established external risk factors include tobacco use, elevated serum cholesterol levels, hypertension, obesity, and decreased physical activity; for various cancers, such risk factors include tobacco use, dietary patterns, certain infectious agents, and environmental or occupational exposure to carcinogenic agents. Even motor vehicle injuries can be associated with multiple factors, including alcohol use, failure to use passenger protection systems, poor roadway design, and inadequate law enforcement. These factors may act independently of each other, the risks being additive according to the effect of each, or they may act synergistically, the interaction of factors presenting a greater total risk than the sum of their individual effects (p.2).

Poverty as a Cause for Unmet Patient Psychosocial Needs

Poverty is a social determinant, and extensive research proves the impact of social factors can be detrimental to the health and longevity of Americans, particularly on lower-income populations. Income, education, employment, access to food and housing, and environmental factors all play a part in the mental and physical health of an individual, and is most pronounced when one or more of these factors are lacking. These findings attribute as much as 40 percent of health outcomes to social and economic factors.

Asthma is linked to living conditions, diabetes-related hospital admissions to food insecurity, and greater use of the emergency room to homelessness...a review of 70 studies found that unemployment and low income were tied to a higher risk of hospital readmission among patients with heart failure and pneumonia. (Bachrach, Pfister, Wallis, & Lipson 2014, p. 7)

Individuals and families with low income and little education are less likely to have health insurance, or enroll in health insurance programs, even if eligible, with minorities making up the majority of the uninsured (“University of Minnesota,” 2013). The uninsured are at the highest risk of not having their psychosocial needs met and limits the individual's access to social services because many do not have a primary care doctor, and frequently let their condition worsen to the point of needing immediate care. “Uninsured adults were more likely to visit the emergency room because they had no other place to go at the time of the last visit (61.6%), compared with adults having private insurance (38.9%) or those with public health plan coverage (48.5%)” (Gindi, Cohen, & Kirzinger 2011, p. 2).

The uninsured are less likely to be