Over the last decade, Payers have begun to recognize the value in addressing social determinants of health (SDOH) within their beneficiary populations, both from a member health and cost perspective. To share more about the concept of SDOH and its potential, we spoke with Lisa Dugan, Senior Director of Integrated Network Development at HHAeXchange. As our subject matter expert in SDOH, she provides insights about why this data is so critical, how Payers can collect the information in a consistent way, and where SDOH fits within the value-based care paradigm shift.
Social determinants of health (SDOH) are the societal factors or conditions that affect a person’s health, functioning, and quality of life. According to the Centers for Disease Control (CDC), they are grouped into five domains:
Education Access and Quality
Health Care Access and Quality
Neighborhood and Environments
Social and Community Context
For instance, a person who relies on a convenience store instead of a supermarket due to transportation issues would be less likely to have good nutrition habits. This can raise their risk of health conditions like heart disease, diabetes, and obesity. Knowing this information helps providers develop a more appropriate care plan that factors in these challenges.
By combining aggregate clinical data with SDOH observations, comparative analysis can reveal which societal factors correlate with conditions or adverse health events. With these insights, Payers can develop protocols for proactively addressing issues when avoidable member risks arise.
In keeping with the example above, having consistent insight into a person’s ability to secure healthy food options on a regular basis within their own community can help to control and even reverse a condition like diabetes over time.
When Payers leverage the predictive potential of SDOH, they can slow the escalation of a member’s health condition or prevent an adverse health event, thus reducing costs.
For instance, just think of the cost of care implications if we can routinely obtain insight into what may or may not be in a person’s refrigerator, or even if a person has a properly working refrigerator. If someone is showing pre-diabetic tendencies, making healthy fresh diet choices available for someone can delay or even prevent the progression of the disease. As a result, the individual leads a healthier life avoiding or minimizing the use of costly drugs, clinical supplies, and the high cost of care intervention often necessary as the disease progresses.
For years, care management and disease management programs sought to standardize diagnosis and treatment options for a particular disease state. The goal was to control costs by attaching a predetermined set of utilization criteria for ruling out or treating a diagnosis. However, the standardized criteria didn’t account for the various non-clinical SDOH factors that may directly impact a plan of care. Thus, clinical authorization and associated reimbursement models didn’t support the need for this kind of data. As the industry is evolving toward value-based care models, Payers are now more incentivized to collect SDOH data.
There is no doubt that Payers will approach SDOH differently. The COVID-19 pandemic has brought so many health-related challenges to the forefront, including the implications of SDOH. With this increased visibility, both 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, we see SDOH reflected in Medicaid Managed Care Organization procurements – as part of the requirements and criteria used to evaluate a proposal for award, associated contractual obligations, as well as the inclusion of SDOH measures in evolving value-based care models and measures. A recent example of this can be found in the Ohio Department of Medicaid’s Request For Applications (RFA) for Ohio Medicaid Managed Care Organizations issued on September 30, 2020. References to Social Determinants and SDOH are scattered throughout the requirements, most notably in sections pertaining to population health management strategy, health equities, care coordination, value-based payment, etc.
With this heightened focus (and now demand) on addressing SDOH, Payers will most certainly need to develop enhanced programs and solutions to track SDOH needs and interventions. Integration with service providers/vendors and/or SDOH-focused networks is no longer a “nice to have” benefit. It’s quickly becoming a staple within the overall benefit package.
When we look at the five domains of SDOH, many tie back to the origin of the person, their home, and the surrounding community. Therefore, an in-home caregiver has the advantage of being at home with the member, thereby gathering firsthand knowledge on SDOH-related observations and facts. Often, these issues may take medical professionals outside the home a long time to recognize, or they might never uncover them, because there’s just not enough day-to-day exposure to the member in their everyday environment. The proximity of the caregiver to the member provides a lot of value, but it’s also the level of trust. This is often necessary when discussing sensitive topics linked to SDOH, especially with the most vulnerable populations.
With the passing of the 21st Century Cures Act, providers and caregivers must use electronic visit verification (EVV) for in-home personal care visits (and skilled homecare visits by January 1, 2023). By piggybacking on EVV, health care stakeholders can leverage this technology to gather SDOH observations as part of a caregiver’s mandated activities. Just a few well-structured questions within the visit verification process can go a long way to identifying needed assistance tied to SDOH-related categories. This approach offers payers and their caregiver network a relatively easy way to start gathering SDOH data.
In a value-based care model, reimbursements hinge on improving health outcomes and keeping costs down. By tracking, analyzing, and acting on SDOH data, Payers can have a much greater impact on these twin priorities. In fact, studies estimate SDOH can be responsible for as much as 80 percent of a member’s health outcome. If providers are just collecting clinical data, Payers are missing a wealth of information.
Going back to our food security example, if someone suffering from diabetes doesn’t have healthy food choices, not just food, but disease-appropriate choices, in their kitchen cabinets or refrigerator, then it’s tough to make a positive clinical impact on that person’s health. Where’s the value in that?
Learn how HHAeXchange Care Insights for Payers can help your organization track, manage, and act on social determinants of health.
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