Although Social Determinants of Health (SDoH) has become a buzzword in recent policy conversations, it is still a powerful tool to analyze the social, economic, and environmental factors that influence consumer activity and overall health. If used properly, SDoH have the potential to improve health outcomes and reduce health care utilization and spending.
Using SDoH, Health Care Service Corp, which operates Blue Cross plans in five states, identified counties in Chicago and Dallas that qualify as food deserts. The company then began meal deliveries to 25 Chicago zip codes and plans to expand the program to 15 zip codes in Dallas. “For us, it’s really part of our effort to address root causes of an expensive health care system,” Health Care Service Corp said.
Others, including many presenters at the 2019 State Healthcare IT Connect Summit, are also focusing on how SDoH can be used to help homelessness, incarceration and child welfare. Investigating why health payers have begun placing a larger focus on SDoH, a recent Deloitte report cited state and federal legislation that requires and encourages plans to coordinate with community and social support providers. The legislation also includes providing a financial incentive to better use resources and ultimately deliver better health outcomes.
One piece of legislation that is now being used by states to support SDoH is the section 1115 waiver, which have primarily been used to support community engagement/work requirements and substance use disorders. The waiver gives the Department of Health and Human Services (HHS) the authority to approve experimental, pilot or demonstration projects that promote Medicaid programs. For example, under the authority of a Section 1115 waiver, Massachusetts developed the Community Support Program for People Experiencing Chronic Homelessness. The program provides enrollees with living skill classes, transportation, health care access and case management services. According to Modern Healthcare, every dollar spent on these services yielded $2.43 in healthcare savings – a significant return on investment.
According to Health Affairs, HHS also now allows the entire clinical care team — from community health workers to nurses — to document social risks in electronic health records through “Z-codes.” For example, Z59.9 corresponds to “Problem related to housing and economic circumstances, unspecified.” Deloitte cites questionnaires, in-person and in-home assessments, risk-stratification through machine learning and predictive analytics, and consumer data as other strategies stakeholders are using to address SDoH.
Despite such activity, Deloitte’s report, which was based on conversations with 14 health plans across four states, details specific hurdles prohibiting more widespread consideration of SDoH. First, while plan leaders say they have been addressing SDoH for a decade or longer, they have not been collecting data or evaluating interventions. When asked why, the leaders cite a lack of in-house expertise to run evaluations, upstream and downstream costs, and a lack of knowledge as to whether a referral to a community-based organization resulted in a member receiving service. While data sharing could solve the latter problem, it often occurs through manual systems that are resource-intensive and inefficient. At least one plan, however, is using a multidirectional data platform using a cloud-based database.
Regardless, most of the interviewed health plan leaders plan to continue their SDoH interventions as it aligns with their mission of improving health outcomes, and because they believe the savings derived will eventually exceed the costs of intervening. As one unnamed health plan executive said to Deloitte, “Addressing SDoH aligns with the head and the heart.” The leaders also believe now is the time to continue to experiment with approaches to contribute to the evidence base and hone business cases.
Since it seems the momentum towards SDoH will only grow, the federal government should continue to support states interested in addressing SDoH. As Margaret Murray, CEO of Association for Community Affiliated Plans said, the Trump administration should continue to approve Section 1115 waivers that creatively address SDoH and make it easier for vulnerable populations to access health services.
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