As SDOH efforts take off, payers try to carve out their role
The healthcare industry is increasingly embracing the idea that a slew of economic and social factors greatly influence medical outcomes, taking on issues from loneliness to food security.
Experts say the move is long overdue. But some say social service organizations should be taking point on managing social determinants of health, and have charged payers and providers with barreling forward on the issue without bringing necessary local partners on board.
"Why don't we follow instead of lead from the clinical perspective, and listen to the people who have been working on this for a lot longer than we have?" Jamo Rubin, president of social risk factor company Signify Community, said Tuesday at the Health Datapalooza conference in Washington.
Most high-profile payers are already tackling SDOH, including Kaiser Permanente, Intermountain Healthcare, UnitedHealth Group, Humana, CVS Health, Anthem, Molina and more. On the provider side, hospitals spent roughly $2.5 billion on SDOH programs from 2017 to 2019, and analysts expect that figure will increase as value-based care picks up momentum and due to federal expansion of coverage for non-traditional services.
Payers acknowledge that social service organizations are critical to addressing the needs of a community on all aspects beyond direct medical care, but say such local players don't have the needed heft to keep tabs on the needs of an entire population.
And, as the U.S. pivots to a more holistic view of health, experts say traditional healthcare companies are still figuring out whether they're leaders or followers in tying traditional medical care to a patient's socioeconomic wellbeing.
"Certainly, on some of the policy or joint convening work, maybe you have a place at the table," Anand Shah, vice president of social health at integrated health system Kaiser Permanente, said. "But it doesn't make sense for the health systems or payers to be driving these conversations."
Though managing SDOH isn't historically a part of medical care, the incentive shift away from paying for service and volume to paying for quality and value has pushed payers and providers in that direction. A late 2018 study found that one in every five patients struggles with a high-risk health problem related to their socioeconomic status.
Some payers think they should be at the helm of crafting SDOH interventions, arguing small agencies don't always have the bandwidth to cover the social needs of a group of beneficiaries.
"We need to start treating social determinants like critical gaps in care," Andrew Renda, associate vice president for population health at Humana, said. "If we don't start treating them like that, they'll be relegated to this nonprofit, grant-funded stuff."
Roughly one in eight human services community benefit organizations was financially insolvent in 2017, according to the Alliance for Strong Families and Communities, a nationwide association of CBOs. The VP of Medicaid policy for UnitedHealthcare called those results "insightful and terrifying" Tuesday.
"What happens if that sector starts to crumble further?" UnitedHealthcare Community & State's Kevin Moore said. "In all these conversations, the focus on the local Mom and Pop place — they don't have the bandwidth."
If a large amount of patients is pushed into a pipeline of organizations that rely predominantly on grants, CBOs could be forced to fold or selectively choose what healthcare companies they work with. That could stop payers and providers from analyzing the effects of an SDOH intervention across an entire patient population.
The multi-trillion dollar health industry by comparison, has resources dwarfing the CBO space. By using its infrastructure, payers and providers could greatly expand the gateway to social services, they say.
For example, North Carolina, a state that has experimented with various Medicaid payment models, is working to embed in its government EHR a link to human service resources like local food banks or domestic violence shelters, according to state HHS Secretary Mandy Cohen.
A role for both
However, though payer executives note they could act as a navigator for social services in an area, they do agree CBOs are critical partners toward the eventual goal of stopping people from coming into the medical system for preventable conditions.
"You can't decide a local health strategy from an ivory tower," Humana's Renda said at a panel on SDOH at Datapalooza.
Proponents of social services groups think their voices should be louder in the national conversation around SDOH, arguing local groups have their finger on the pulse of a community and often know a person needs socioeconomic help before they make it onto the healthcare system's radar.
"With all due respect to my physician colleagues, in four years of medical school and then residency, I never learned one thing about what happens to people after they get discharged," Signify Community's Rubin said. "What I did learn is, once they've entered the medical system, it's too late."
In an effort to prompt physicians to engage with social needs, CMS introduced coding for SDOH factors in 2016. But adoption of the so-called Z codes has been lackluster. According to a late January report from CMS, in the first two years the codes were available in Medicare fee-for-service claims, they were used for only 1.4% of beneficiaries.
Yet there's a role for payers, providers and CBOs on identifying SDOH needs and connecting patients with resources in their communities, experts say. For example, doctors can identify need and refer patients to community organizations, and payers can reimburse for CBO services.
Just a quarter of hospitals and 16% of physician practices screen for all five factors CMS has prioritized: food insecurity, housing instability, utility needs, transportation needs and interpersonal violence, according to a JAMA study published in September. But a clear majority of Americans want their doctors to ask them about their social needs.
With the current need to address SDOHs, "I don't think we have the luxury to try to figure out if one specific sector should take responsibility," Moore said, noting a slew of players should be working to create touchpoints to connect people to the care they need, whether social or medical.
"That's what we're trying to work to — not who gets credit."
Article top image credit: Roger Wollstadt