Hi, I’m Lauren Carpenter. I’m ScriptDrop’s writer and researcher. I run The Beat. Since January 2020, every blog post has been written by me. Generally I strive for a highly objective, just-the-facts-ma’am tone. But today we’re getting personal.
The patient journey is different for everyone. We’ve discussed that fact again and again by examining the social determinants of health (SDOHs). These (and other factors) cause major health disparities and can cause poor medication adherence. One of the ways to solve poor adherence is through prescription delivery. But it’s easy to brush off those ideas in the abstract.
Let’s see how SDOHs function in real life. Come with me on a trip to the doctor.
Social determinants of health
First, let’s review the social determinants of health. If you read our 2022 industry report, you’ll remember these.
- Economic stability
- Education access and quality
- Healthcare access and quality
- Built environment
- Social and community context
SDOHs can be used to predict what healthcare obstacles patients face and what kind of interventions they might need. They are not meant to fuel judgments about patients. Everyone deserves the same standard of care, regardless of where they fall on the spectrum of a given determinant.
Now let’s see how these apply to one simple doctor’s visit.
The set up
Today I have my annual gynecologist appointment. Even this simple thing – having a previously-scheduled appointment and being able to go to it – is a privilege. In terms of the social determinants of health, this is a sign of my economic stability.
I’m able to work full-time. I have the benefit of living in a two-income household. I have good health insurance through ScriptDrop, and the company pays almost all of my monthly premium (an incredible benefit!). For all these reasons, I’m able to make the preventative care appointments I need.
My team is also really flexible, so it’s not a problem if I need to leave work during the day for a doctor’s appointment. If I worked in a rigid office environment, I might have to use a sick day instead. If I still worked an hourly service job, I would’ve had to put work first, reschedule my appointment, and delay my care.
If I had a different living situation, I might think twice before making non-urgent appointments at all. For example, between undergrad and graduate school, I was working part-time in food service and was not economically stable. This was before the Affordable Care Act allowed people under 26 years old to stay on their parents’ insurance, so I was completely uninsured. Even when I started my grad program and received health coverage through my university, I wasn’t paid enough to afford any “extra” health services.
As a result, I waited until after grad school to see a doctor for my mental health concerns and severe gastrointestinal symptoms. In hindsight, it isn’t surprising that I was diagnosed with inflammatory bowel disease, was suffering from serious vitamin D and B12 deficiencies, and needed an SSRI to control my depression. If I’d been diagnosed earlier and had received medication when I was 22 instead of 27, my quality of life would have been so much better.
Getting there
As luck would have it, my partner has to go into the office for work and needs our shared car to get there. No matter. This doctor’s practice is less than two miles from my house. Ding ding! There’s the social determinant of healthcare access and quality. The fact that I have a great doctor so close to home is a serious privilege. If I lived in a more rural area, the nearest gynecologist might be 25, 50, or even a 100 miles away.
I could afford a rideshare, like Uber or Lyft (hello, economic stability). They’re easy to find in my neighborhood, which is an element of built environment. But I’m trying to get more exercise, so I decide to walk. I can make this choice because I know I don’t need to rush to my appointment and back.
I quickly discover that my walking route would be inaccessible to anyone with a disability or using a mobility aid. Sidewalks simply end once I cross over into a wealthier neighborhood. I have to walk in the street. At several points I have to cut through parking lots, creep along the edge of a field, skirt huge construction sites, and scamper across busy, multi-lane roads. By the time I get to my doctor’s office, I’m angry. The built environment of this area was designed only with cars in mind, not human beings. It’s completely inaccessible not only to people with disabilities, but also to anyone without access to a car. A car is the only sensible way to get there. Taking a bus isn’t even an option; there aren’t any routes that go directly to this area.
The appointment
My appointment is easy in comparison to my journey on foot. This is where the SDOH of education access and quality comes into play.
As a kid, my parents read to me. My mother took me to the library every week. My grandfather, an English professor, encouraged me to write. When the internet became widely available, my father bought the family a computer. That opened up the world to me.
While a lot happened along the way, that foundation of reading, writing, and research eventually led me here to ScriptDrop. Here, I’ve learned how doctors, pharmacies, and insurance payors interact. I know how to talk to my doctors about my symptoms. I know what questions to ask, and I know what questions they’ll ask me.
My past healthcare access and quality is also significant. As a teen, I had fainting spells. After one total blackout, my mother rushed me to the ER. That led to a year of electrocardiograms, blood draws, a CT scan, an MRI, a Holter monitor, an echocardiogram, an electroencephalogram, and a cardiac stress test. I got used to seeing new doctors and answering the same questions over and over. Eventually, a pediatric cardiologist diagnosed me with borderline Long QT syndrome.
But if I had lived in a city without access to those services or if my parents hadn’t been insured, none of those tests and appointments would have happened. There’s some chance that I could’ve died at a young age if I hadn’t known to avoid medications contraindicated for Long QT. My health literacy – and my survival – is directly tied to my family’s social determinants of health.
When the doctor comes in, I’m ready to answer her questions about how I’ve been feeling, how my medications are treating me, and any concerns I might have. Once my exam is over, I’m free to get dressed and make the long walk home.
I note that she doesn’t ask whether I’ve been adherent to my medications. I have been, because I have the economic stability to afford them and healthcare access isn’t a problem; my default pharmacy is a five-minute walk from my house. (The built environment is better, too, since my route has decent sidewalks and a consistent bus line.) But she doesn’t know all of that.
In fact, by the time I slog home, I’m exhausted. If the doctor had sent a prescription to my pharmacy right after my appointment, I wouldn’t have gone to pick it up. My healthcare access might be excellent, but that doesn’t mean I’ll always make the choice that my doctors would prefer. Despite all my privilege, I too would benefit from prescription delivery.
What it all means
We’ve talked about the social determinants of health as a spectrum. Right now, I’m on the positive end of all five. Why? Not because I worked for it. It’s because I am extremely privileged.
Consider:
- I am white.
- I am cisgender.
- I speak English without an accent.
- I have a full-time job.
- I have commercial insurance through my employer and I am able to pay my medical bills.
- I do not have any addictions.
- I do not have any visible disabilities.
Because I look, sound, and act in certain ways, people in my community (including healthcare providers) have a positive bias towards me. Because I have that positive social and community context, it has been easier for me to get a job and become financially stable. Because I have economic stability, it’s easier for me to gain healthcare access, enjoy further education access, and ignore the obstacles of my built environment.
And yet I’m not a perfect patient. I asked my doctor for a list of dermatologists she recommended, and it took me two years to make an appointment. One of my maintenance medications is supposed to be taken three times a day, but I often skip the middle dose. Once I went a whole month without that medication, because the pharmacy didn’t have it in stock and I didn’t make the effort to transfer the prescription. Any of these choices could harm my health, and I know that. I’m not doing it out of spite towards my doctors and pharmacists. It’s just hard to balance my own health against everything else in my life.
So what does this mean for healthcare providers, pharmacists, hospital administrators, insurance payors, pharma companies, and everyone else who holds sway over a patient’s care?
I believe that while the social determinants of health do indeed determine a patient’s access to care and can predict what kind of choices they will make, we cannot use SDOHs to make assumptions or judgments about patients. Do not use them as a way to assess some patients as “good” and others as “bad.” Do not use them as a way to create policies that give some patients substandard care. Use them as a way to understand the complexity of the patient experience.
After all, healthcare is about human beings, not numbers. We’d all do well to remember that.