Social Determinants and Health Plans: Getting Started | Geneia

Social Determinants and Health Plans: Getting Started

June 12, 2019
Heather Staples Lavoie, President


Health plans are moving from pilots to addressing social determinants of health challenges at the population level

Without a doubt, social determinants of health impact health outcomes. Recent research suggests medical care accounts for only 10-20 percent of health outcomes while the other 80-90 percent are attributed to demographic, environment and socioeconomic factors. At the same time, studies have shown that most patients have at least one social determinant of health (SDoH) challenge.

Given the prevalence and profound impact social determinants have on health outcomes, it makes perfect sense that addressing a member’s housing, transportation and food needs reduces health spending. Health plans have led the way with pilots and research studies demonstrating the effectiveness of managing patient social determinants:

Social Determinants of Health in Action

With 59 percent of healthcare payments expected to be within value-based care models by 2020, payers are increasingly moving from SDoH pilots to addressing member social determinant challenges at the population level.

A combination of publicly-available county and zip code data and member-level social determinant information can dramatically improve the effectiveness of care planning for members, if made readily available to care managers. For example, the payer care manager responsible for a member with congestive heart failure, hypertension and type 2 diabetes, and social determinant indicators for housing and transportation could leverage that information, drilling into the patient record to see information such as:

  • The member moved three times in the past 12 months,
  • There is no known licensed driver in the household,
  • The closest in-network pharmacy is nearly a mile away from the member’s current residence.

Social determinant information presented in this manner suggests transportation is the reason the member has not recently filled their prescriptions. In this case, the health plan care manager would contact them to confirm they do not have access to a car and the distance to the nearest bus stop. Within the patient record, the care manager could arrange for medications to be sent to the patient’s home as well as create a referral to a social services organization that provides transportation to physician visits.

Similarly, care managers can identify and address populations or subpopulations with social determinant gaps. For example, an employer with a high prevalence of diabetes and prediabetes among employees and dependents can work with a payer care manager to determine if social determinant barriers such as hunger, access to healthy food options and/or the absence of parks, playgrounds and sidewalks are adversely impacting employees’ ability to embrace the kind of lifestyle changes needed to manage diabetes and prediabetes. The employer may also choose to add healthier options in the company cafeteria, replace vending machines with fruit bowls and install fitness equipment in the workplace.

For more information, download Geneia’s white paper, Social Determinants of Health: From Insights to Action.

Download the white paper


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