Why Social Determinants of Health Are a Critical Factor for Preventing Member Risk Escalation in the Value-Based Care Equation


Medicaid managed care organization (MCOs) may be better equipped to address social determinants of health (SDOH) and health equity than payers who use fee-for-service models because SDOH are central to many requirements for MCOs, including those pertaining to population health management, health equity and care coordination.

The role of homecare providers is central as the industry transitions to value-based care. Rather than reimbursing providers based on the quantity of services delivered, value-based care rewards providers for the quality of their services and their impact on member outcomes.

Kim Glenn

Kim Glenn

However, when considering factors that impact the health of a member receiving care in the home, the quality of care that a provider delivers is not the only factor in ensuring a member achieves optimal results. Likewise, clinical factors, including access to medical care and the quality of that care, also can only make so much of an impact. What’s truly most influential are social determinants of health (SDOH), which influence more than 80% of health outcomes. SDOH include social and economic factors, including level of education, employment, income, community safety, family and social support; health behaviors, such as tobacco, alcohol and drug use, diet and exercise; and physical environment, including air and water quality, housing, transportation, and access to healthy food.

For providers to effectively deliver value-based care and proactively minimize health risks, they need to understand how SDOH are impacting their members. But getting that data and assessing it to provide optimal care can present a challenge. The first hurdle is often the member themselves. Many are not comfortable providing sensitive information, or may not be completely upfront about their lifestyle, which can make it difficult for providers to see the full picture. Members may also have concerns about how this personal information may be used.

Eliminating blind spots

Given that SDOH significantly impact member outcomes, there has been a greater emphasis on these factors in value-based care models among both providers and payers. Effectively addressing SDOH is the key to improving member outcomes and lowering healthcare costs through prevention of worsening chronic conditions and the need for emergency care or lengthy hospital stays.

Historically, care and disease management programs relied on standardized diagnosis and treatment options for particular conditions, with the primary goal of controlling costs. But these were not as impactful as expected because they did not account for the various non-clinical SDOH factors that may directly impact a plan of care. Now, with more focus on value-based care models, there is a stronger incentive to collect SDOH data.

But finding the best solutions to bring together both clinical and SDOH data to gain a holistic view of a member or population — and to share that data among key stakeholders — has been a weak spot the industry must address. The key to success is being able to connect the full network of stakeholders — from members, providers, and payers, to home healthcare workers, community based support organizations, government entities, and mental health providers — and to ensure they have the right data to achieve a comprehensive view of the care and other services individuals may need.

The COVID-19 pandemic acutely revealed the significant implications of SDOH on the health of certain populations. As a result, the Centers for Medicare and Medicaid (CMS) and state Medicaid programs are driving greater investment efforts into the innovations and solution initiatives surrounding SDOH. For example, Medicaid managed care organization (MCOs) may be better equipped to address members’ social determinants of health and health equity compared to fee-for-service models. References to SDOH are central to many requirements for MCOs, most notably when pertaining to population health management strategy, health equities, care coordination and value-based payment.

The ability to combine and analyze clinical data and SDOH observations, and having purpose built technology and tools that give all stakeholders insights into the societal factors that correlate with specific conditions or adverse health events, is more important than ever. With a more detailed, 360-degree view of all factors impacting members’ health, providers and payers can proactively address issues to reduce adverse and costly events and ensure members have the chance to lead healthier lives.

Kim Glenn is the senior vice president of government health plans at HHAeXchange.

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