The folks behind the SAT — that rite of passage for many college-bound students — announced last month that colleges will also receive a measure of the overall disadvantage level for every applicant. This so-called “adversity score” is based on the social and economic conditions where the student lives and the high school they attended, not personal data.
The score reported to the college includes neighborhood factors such as crime rate, housing stability and the percentage of students eligible for free and reduced lunch. The goal is to give colleges more data to evaluate an applicant’s potential. These same factors are equally important to health outcomes — let’s call it a “Health Adversity Score” — but more on that later.
The rationale is simple: an SAT score is not just a measure of a student's innate ability. If it were, then there wouldn’t be an entire industry devoted to helping kids get higher scores. An SAT score is also a reflection of the child’s advantages and disadvantages.
Think of the adversity score like a golf handicap designed to level the playing field for students pursuing higher education. Not every child went to summer enrichment programs, was tutored through tough courses, received SAT test prep, had a stay-at-home parent or high quality childcare, lived in a quiet neighborhood, had parents who didn’t work a night shift or safe streets or good parks or libraries open on weekends or fast internet or lead-free housing, etc., etc. In fact, these are some of many factors large and small that also determine health outcomes.
So what lessons can we apply to health outcomes?
Imagine the patient who’s regularly late, misses appointments or doesn’t fill their prescriptions as instructed. From the physician’s and the front-office staff’s perspective, this is a non-compliant patient — a pain in the neck who messes up the smooth flow of the practice and makes the doctor look less effective. These are patients they may want to avoid.
Flip the picture around and you see a patient who’s struggling with a life out of balance. Transportation and financial issues cause chaos, and following the doctor’s orders may not be their highest priority or even possible. It’s hard to get a prescription filled if you can’t afford a copay or work long hours and have no one to pick it up when the pharmacy is open. Following detailed instructions is a challenge for people with limited reading ability or are just plain tired after working two jobs. These health adversities are not typically captured in the medical record.
Like an Educational Adversity Score, a true Health Adversity Score would show how the financial health of hospitals is also impacted when they serve disadvantaged communities. Hospital revenue increasingly depends on the outcomes of the care they provide. For instance, they can be penalized for unnecessary readmissions and long lengths of stay. Yet, the patients some hospitals serve have less support at home and in the community, making these unfortunate events more likely. A Health Adversity score takes into consideration the overall state of health and challenges of the people the hospital serves.
Unfortunately, unlike education where a disadvantaged student can catch up if given the right opportunity, people with a lifetime of health adversity will always be behind their peers. So we must explicitly acknowledge the health challenges that lie behind a high adversity score and work with people and communities to fix them. The end result will be a health care system that doesn’t treat people as if they are all the same, but factors in the many advantages and disadvantages each of us have.