Why Value-Based Care is Incomplete Without Considering Social Determinants of Health

Health care payers and providers must address the social needs of patients to deliver complete care

This is the first post in a four-part series about social determinants of health (SDOH). This post provides an overview of SDOH and frames additional issues in the field. Subsequent posts will focus on data standards for improving the collection and use of SDOH, measuring quality in the context of SDOH, and evaluating programs that address SDOH.

In January 2018, a woman in Baltimore was found outside on a freezing cold night wearing nothing but a hospital gown and socks, having been recently discharged from a local hospital. Video of the event made national headlines, prompting an apology from the hospital and an investigation from the Centers for Medicare and Medicaid Services (CMS). CMS’s reports highlighted a number of deficiencies in the circumstances that led to the woman’s situation, including lack of compliance with the laws that govern emergency departments (ED) and how an informal “un-discharged” function led to inaccurate counting of ED visits and tracking of patient care. Remedying the deficiencies in the report may prevent another incident of inappropriate discharge, but they would do little to address the underlying causes that led to the woman’s plight, including poverty, mental illness, and housing insecurity.

The U.S. health care system was never designed to address the complex social needs that contributed to the events in Baltimore, and there is growing recognition of and research into the ways social factors—often referred to as “social determinants of health”—impact people’s health and well-being. The CDC defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks,” and the World Health Organization notes that they are the root cause of most health disparities.

As the U.S. works to transition to value-based care, SDOH have taken on a more central role because they touch on many areas that affect health, but that physicians cannot directly impact and that no single government agency oversees. For example, the Department of Health and Human Services administers Medicare and Medicaid, and the Department of Agriculture administers food stamps, but neither oversees public housing.

As research into SDOH has grown, there is also a need for information to be tracked, integrated, and used effectively to connect people with needed services and to identify ways to strengthen communities. One key example of this is the need for the development of standards that allow organizations to consistently track and document critical SDOH information. For example, how can organizations consistently document that a person faces housing instability, and how can we collectively ensure that health care providers and social service organizations can share and act on that information?

Another issue relates to how payers, including the federal government, pay for quality. There is a long-standing debate about how to include markers of vulnerability within quality measures. For example, if providers are evaluated and paid based on how well their patients’ diabetes is controlled, should the accepted performance rate be lower if a portion of those individuals face food insecurity or unstable housing with no reliable way to refrigerate insulin? Offering the same payment for a lower performance rate could suggest that it is acceptable for vulnerable patients to receive lower quality care. However, not including information about social needs could result in penalties for providers who treat the most vulnerable patients. The acceleration towards value-based care makes these issues even more urgent.

To evaluate and understand how to improve health and well-being, alignment, collaboration and planning at the community level are all needed. Comprehensively addressing SDOH will require an alignment of incentives across sectors, better application of data to target resources, and community-level innovation. To continue on this path, we must have ways to share and use information. The next post in this series will focus on how standardized data can help this process.