COVID-19 Boosts Focus on Social Determinants of Health

COVID-19 has increased the healthcare industry’s focus on the importance of addressing risks and needs related to social determinants of health (SDOH), especially for people in vulnerable communities or those who are otherwise at higher risk for adverse health outcomes. The ongoing public health emergency spurred by COVID-19 resulted in a rise of unemployment, housing and food insecurities, transportation barriers, and isolation, all of which are SDOH-related risks that can negatively affect a person’s health, result in adverse outcomes and increased utilization (e.g., emergency department visits), and contribute to growing healthcare costs. The pandemic has also exacerbated and magnified existing racial and ethnic health disparities. Along with their increased exposure and susceptibility to COVID-19,  Black, indigenous, and other historically marginalized minority populations have poorer overall health outcomes, are less likely to have health insurance, and use or have access to fewer preventative services. 

The pandemic has highlighted key challenges with unstructured approaches for addressing SDOH-related risks and needs in clinical settings. There is a lack of consistency in assessing these risks and needs at the point of care and a lack of standardization in measuring successful interventions. There are also challenges with healthcare providers’ ability to identify available resources and share information with community-based organizations that are best-suited to help address these issues.

Value-based payment programs (VBP) offer a solid opportunity for payers and providers to test new ways of providing care that better address SDOH-related risks and needs. According to the Centers for Medicare and Medicaid Services, “Value-based programs reward healthcare providers with incentive payments for the quality of care they give to people with Medicare. VBPs help us move toward paying providers based on the quality, rather than the quantity of care they give to patients.”  

Public and private payers alike have demonstrated an ongoing commitment to addressing health disparities and equity through VBPs. Most recently, CMS and the Centers for Medicare and Medicaid Innovation (CMMI) issued significant statements on the importance of advancing health equity to their 10-year vision for CMMI and to driving innovation in programs that address behavioral health and SDOH.

We’ve identified the following areas of exploration that are potentially instructive regarding the design of future VBPs to address SDOH-related risks and needs. 

While many clinicians have implemented validated screening tools for SDOH-related risks and needs, there are inconsistencies across VBPs for assessing risks and needs at the point of care. Some progress has been made through alternative payment models (APM) like CMS’s Accountable Health Communities and Comprehensive Primary Care Plus initiatives where providers are integrating social needs assessments, building community resource networks, and developing referral and tracking processes into primary care delivery. Unfortunately, not all VBP programs require providers to assess for SDOH-related risks and build processes to address related needs, and such practices are not yet consistently included in VBP risk methodologies. With the growing adoption of VBPs across payers and healthcare providers, incorporating expectations for assessing and addressing SDOH-related risks and needs will help us further understand the prevalence and impact of social needs across patient populations. 

There are also inconsistencies in the specific risk factors that are assessed within existing screening tools. Some tools assess multiple risk domains, such as transportation access, housing instability, and financial strain, while others assess a single domain. And unless participating in a VBP that requires it, screening for these risk factors at the point of care is voluntary for providers, leading to inconsistent data collection and gaps in the ability to track equitable outcomes. Standardization of evidence-based screening tools that assess multiple risk domains and incorporate socio-demographic information would lay the foundation for a more data-driven approach to population health management inclusive of addressing SDOH-related risks and needs, as well as the ability to better deliver equitable outcomes. Relatedly, this data could be evaluated to determine whether it should be built into VBP risk models to better control for social needs across patient populations and incentivize providers to work with more complex populations.

To optimize how we coordinate care, we must bridge communication across health, social, and community-based organizations, and the individuals they serve. A bi-directional, electronic exchange of clinical and social data is optimal, but comes with some challenges. There needs to be a clear definition for how information on SDOH-related risks and needs is defined, captured, and exchanged. To exchange information electronically, health data must be entered into electronic health systems using the code systems and value sets that are standard for interoperability. This is a medical-centric approach and will need to make considerations for social systems that may differ ontologically. The Interoperability Standards Advisory has begun work to develop SDOH data standards. 

In March 2020, the Office of the National Coordinator for Health Information Technology released its final interoperability rule as part of the 21^st Century Cures Act. This ruling advances interoperability and health IT certification, and gives patients greater digital access to their health information, but the data classes included in the interoperability rule are still limited. At this time, “social, psychological, and behavioral data”, which are described as, “conditions in places where people live, learn, work, and play that affect a wide range of health risks and outcomes” fall under data classes that are considered critical to interoperability but require further clarification. Questions designated for additional examination include: How does this data fit into Health Insurance Portability and Accountability Act (HIPAA) Rules and expectations for obtaining informed consent, and what specific SDOH data elements will the Office of Civil Rights approve as allowable to share with non-covered entities?

VBPs use performance-based metrics that are linked to financial incentives. One set of metrics they commonly employ are electronic clinical quality measures (eCQM) which are designed to measure processes and health outcomes in a clinical setting. There are eCQMs for medical conditions like hypertension and diabetes, for example, and for behavioral health conditions like depression and suicide. However, there are currently no eCQMs specific to assessing or addressing SDOH-related needs and risks. To bring social needs to center stage, SDOH-related measures must be developed and integrated into VBP quality performance metrics, and health equity outcomes must be considered in model evaluations. To accomplish this and ensure broad adoption, CMS should work in partnership with the National Council for Quality Assurance and the National Quality Forum, as well as with healthcare providers and other stakeholders.

About the author: Jennifer Boaz, MHA, BSN, RN, is an associate at Booz Allen Hamilton, and brings over 15 years of experience in clinical care and operations, integrated primary care, population health, and quality improvement. She currently supports learning system activities for CMS advanced alternative payment models.