Greater use of the emergency room by the homeless, alongside food-insecurity-induced diabetes-related admissions and stroke risks attributed to loneliness are just some of the ways in which social determinants of health (SDOH) have recently gained attention as key factors in shaping health outcomes. Defined by the World Health Organization, SDOH refer to the conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources. These determinants are crucial for understanding health disparities, particularly among Medicaid and Medicare recipients, who are dual-eligible, are primarily low-income and face greater social challenges.
Since the concept of SDOH was introduced, significant events like the COVID-19 pandemic have highlighted the stark health inequities faced by people of color, intensifying the urgency to address these disparities. For Medicaid and Medicare, addressing SDOH means not just meeting medical needs but also tackling the social and environmental factors that undermine health. This approach is essential for advancing equity and improving the well-being of the most vulnerable groups in society.
The Imbalance Is Not Good Enough
As Medicare and Medicaid programs shift their focus from the volume of services delivered to the quality of health outcomes, the emphasis on addressing these social needs has become more pronounced.
Recent strategies have shown that addressing the SDOH can be both cost-effective and impactful, particularly for high-need populations. For example, providing supportive housing for seriously mentally ill individuals who might otherwise be homeless can dramatically reduce expenses related to emergency department visits and inpatient care. Similarly, linking low-income seniors with chronic conditions to food assistance programs like SNAP or arranging for home meal deliveries has proven to decrease healthcare costs and reduce the frequency of medical interventions.
However, the U.S. healthcare system, despite its considerable spending, still falls short of effectively addressing health disparities among Medicaid recipients. Medical care accounts for only 10-20% of the modifiable contributors to health outcomes, with the remaining 80-90% influenced by SDOH. Comparatively, other developed countries invest more in social services, highlighting a gap in the U.S. approach.
This imbalance often results in medical solutions that overlook essential social needs. For example, treating a patient with mental health issues without addressing their social isolation misses broader determinants that impact health. Healthcare professionals must adopt a more humble and open approach, prioritizing community engagement and collaboration over traditional medical interventions. This shift towards integrating community resources can lead to more effective and holistic care for the Medicaid population.
Keeping SDOH in Focus
SDOH interventions can be cost-effective. However, the challenge of ensuring SDOH is kept in focus demands a broad-based strategy that pulls in healthcare systems, providers, and insurers – including Medicare and Medicaid – along with social services, community groups, and policymakers.
State Medicaid programs, for instance, are evolving. They increasingly leverage managed care organizations (MCOs) to connect beneficiaries to crucial social support as a part of their care management duties. Moreover, innovative payment models like Value-Based Payments are reshaping how care is delivered and funded. These models reward providers for achieving health outcomes, not just for the quantity of care delivered, thus providing more incentive for providers to offer more holistic services, such as securing housing for homeless beneficiaries, which can prevent costly medical interventions in the future.
How to Recognize and Address Social Needs
Recognizing and effectively addressing social needs within the healthcare system, particularly for Medicare and Medicaid enrollees, hinges on employing multiple modalities to identify these crucial factors. Health plans typically use health risk assessments (HRAs) and questionnaires—administered by phone, online, and mail—to screen members upon enrollment, annually, or after significant medical or life events. However, the completion rates for these assessments are generally low, often below 50%.
To enhance the effectiveness of these screenings, in-person and in-home assessments are increasingly favored, demonstrating boosted completion rates of up to 80-90% while providing deeper insights into the enrollees’ living conditions and personal challenges. For example, a visit to an enrollee’s home can reveal critical social determinants like unsafe living conditions or signs of interpersonal violence that might not be disclosed in a questionnaire.
There’s also a greater push for leveraging advanced technologies such as predictive analytics and machine learning to assess the impact of SDOH. By combining demographic, geographic, and medical data with insights from social needs assessments, these tools help stratify members by risk and predict social needs more accurately, allowing for targeted interventions and more personalized care management.
Using What’s Available
While still in the learning phase, Medicaid and Medicare Managed Care Organizations and other health plans must look ahead and experiment with innovative approaches to address SDOH. There’s a library of research surrounding the use of new technologies, virtual care, and data analyzing platforms, and it’s therefore high time for older strategies to be reformed so that their impact can expand to bigger and healthier communities.
Jayme Ambrose
Jayme Ambrose is CEO of Adobe Population Health.
