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What are the challenges and issues involved in estimating any ROI on Social Determinants of Health

David Fairchild, MD, MPH was featured in the April/May edition of MCOL Thoughtleadersnewsletter. The question asked was:

What are the challenges and issues involved in estimating any ROI on Social Determinants of Health (SDOH) initiatives, and to what degree do you see ROI pressures being applied now or ultimately to SDOH investments?

The World Health Organization has defined the Social Determinants of Health (SDOH) as, “The conditions in which people are born, live, work, and age.” The WHO goes on to say that “these circumstances are shaped by the distribution of money, power, and resources at global, national, and local, levels.” Social determinants are a cause of a number of major health inequities including heart disease, obesity, diabetes, drug addiction, alcoholism, and a variety of mental health issues. The growing inequalities of health and wellness in many communities in the midst of economic growth and concentrated wealth has helped to direct attention to SDOH.

Further, the advent of value-based contracting and population health programs has required clinicians like me to take a more holistic view of the circumstances in which our patients work and live.

There is a long list of social determinants of health including transportation availability, safe housing, physical environment, racial segregation, access to safe drinking water, food insecurity, that impact community health. Recent research has shown social determinants, in fact, have a higher impact on population health than healthcare services; and that states that allocate more resources to social services than to medical spending have improved health outcomes over states that do not. Data availability, of course can be challenging. But the rapidly emerging field of data analytics has opened the door for companies such as LexisNexis Health Care which gathers SDOH data from public sources to help predict which patients may be facing serious health issues, and the National Association of Community Health Centers which has developed a risk-based SDOH tool for interviewing patients.

Previously viewed as simply beyond the scope of provider systems, SDOH have historically been overlooked in clinical practice. However, the move from volume to value-based contracting has opened the eyes of providers to the financial impact of SDOH and has prompted an increasing number of provider systems to address SDOH as an element of their population health strategy. A new set of SDOH standards identified by the Institute of Medicine in 2012 identified 12 different SDOH measures that are only recently becoming used in clinical practice. SDOH initiatives focus on community partnerships that may offer food, temporary housing, and transportation. Organizations such as Montefiore Health System in the Bronx have reported a well-publicized “300% ROI” on their community housing program which has reportedly reduced ER visits and readmissions among high risk and chronically ill patients. Other providers are partnering with community organizations and are using data to identify frequent users of ER services and link them to primary care providers.

The good news is that the move toward population health management will fuel local SDOH initiatives that can generate a ROI in a value-based reimbursement environment. But it should be clear that these SDOH efforts are not focused on improving the underlying social and economic conditions of these communities to foster improved health for all—they are primarily about ameliorating the social service needs of individual patients, and by doing so securing better outcomes for the provider’s value-based contracts. Our own experience is that the most successful population health program will have an SDOH focus as part its efforts. These investments in social and community services are essential, especially for any providers dealing with high risk dual eligible and Medicaid patients.

As we start to normalize the tracking of SDOH metrics, the next question will be should we hold providers accountable for performance on these metrics-as we do now for quality? Based on a decidedly unscientific “biopsy” of medical institution hallway conversations, being accountable for social factors makes providers very nervous.

Nevertheless, holding provider systems accountable for performance in this area is a potentially powerful tool, even more so if in doing good, provider systems can also do well.

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