Addressing Health-Related Social Needs in the Clinical, Community, and Policy Domains

“The effects of social determinants of health (SDOH) on health outcomes have been extensively evaluated and described. Efforts to elucidate the impact of specific unmet health-related social needs (HRSN), such as food insecurity and lack of transportation, on specific outcome measures can help pinpoint necessary interventions and policy changes. [..]

In recent years, the Centers for Medicare &Medicaid Services (CMS) have placed higher priority on addressing health equity, including directly addressing unmet HRSN and accounting for social risk in Medicare payments. For payments, a growing body of literature has demonstrated that health care systems caring for patients with higher social adversity perform worse on quality and utilization measures and are more frequently financially penalized, which can lead to a sort of “reverse Robin Hood” outcome of redistributing resources away from safety nets to wealthier health care systems caring for more affluent patient populations. Recently, CMS has begun to adjust payments according to social risk with alternative payment models, such as ACO REACH (Accountable Care Organization Realizing Equity, Access and Community Health) and the Maryland Primary Care Program, that use the area deprivation index (ADI) to adjust payments according to the level of social adversity faced by beneficiaries, based on neighborhood (census block)-level data. In 2023, Medicare’s Shared Savings Program also began adjusting payments based on social risk using ADI.

Using area-level indices has distinct benefits, most notably the lack of administrative burden and availability for all patients. In contrast, survey-based HRSN data are not readily available for most patients. Active screening for HRSN during health care encounters is increasing but also has challenges: training staff to collect data in a robust but sensitive manner, time and administrative burden to conduct screening, and concern that individuals at highest social risk and those historically subjected to discrimination may be the least able or willing to provide individual-level data due to infrequent contact with and historical mistrust of the health care system. As screening increases, hybrid approaches using individual- and area-level data to account for social risk should be explored, and further research to determine how best to apply such methods is needed.

Despite the challenges, collecting individual patient information on social adversity and HRSN can be done with trained staff and clinical personnel who understand trauma-informed care approaches to discussing this sensitive information and who develop longitudinal, trusted relationships with patients. Ideally, such efforts would be done in partnership with public health team members who are skilled in qualitative interviews and thematic analysis conducting community needs assessments. Collectively, such efforts, along with advancing data platforms and alternative payment models, hold promise to accelerate the integration of traditional health care and social services to better care for patients and communities. Tracking unmet HRSN and community needs can support advocacy efforts for additional local, state, and federal funding for community resources. Integrated data can also enable coordinated social services to better allow community-based organizations to address cooccurring needs in a comprehensive rather than piecemeal fashion. These data can also enable better design of care teams to address health in the context of high rates of unmet personal HRSN and within the context of the communities in which people live. As advanced payment models move health systems away from fee-for-service reimbursement for limited clinical services and toward prospective payments with flexibility to use resources further upstream, such care teams may be able to more directly address HRSN that are contributing to worse health outcomes.

Ultimately, a combination of individual-level and area-level indicators of unmet HRSN and neighborhood deprivation could help channel existing health care and social service resources in a more coordinated and comprehensive fashion to better meet the needs of patients and communities. However, even such an approach may remain too far downstream to address many of the drivers of poor health, and overmedicalization of SDOH can also have negative consequences. As such, advocating for antiracism and antipoverty policies that provide large-scale investment in social services, even at the expense of health care funding, may prove to be the most critical strategy to improving health outcomes.”

Full commentary, A Chen, K Gwynn and S Schmidt, JAMA Network Open, 2023.4.21