The Economics of Social Need

Policymakers and payors are recognizing the importance of social determinants of health.

Nov 19 Silva

What does it take to keep people healthy? Certainly, high-quality clinical care is important. But the relative contribution of clinical care is lower than we think. Data suggests that clinical care impacts only 10–20% of overall health.1 Think about that for a moment. Clinical care addresses only a small percentage of population health. About 80–90% of overall health is determined by social determinants of health (SDOH).

SDOH are the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.2 The data are far-reaching. In my home state of Texas, for example, around 9.5 million people screen positive for unmet social needs.3,4 Let’s look at one SDOH and its effect. Food insecurity is the disruption of food intake or eating patterns because of lack of money and other resources.5 If we look at the diagnosis-related groups (which determine inpatient payments) for malnutrition, meaningful trends emerge. There is a direct correlation between increased payments for those diagnosis-related groups and counties with a high number of food deserts (locations lacking access to healthful whole foods).6 On a practical level, people experiencing food insecurity often are forced to choose between food and other essentials such as medications or the transportation necessary for their medical care. This becomes relevant for physicians who may have their quality performance scored by metrics, such as medication adherence or diabetes control. Both are influenced by SDOH.

Policymakers and payors have been slow to recognize the importance of SDOH in healthcare. For instance, MIPS includes about 250 measures — none of which relate to SDOH. But this circumstance may be changing. In late 2018, Alex M. Azar II, the U.S. Secretary of Health and Human Services, indicated that the administration was evaluating the role SDOH play in healthcare.7 In 2017, CMS created the Accountable Health Communities model to identify patients who use extreme amounts of healthcare services for factors of social and health insecurity. When such needs are identified, the project helps arrange navigators who can match them with community resources.8

Private payors are also increasingly recognizing the impact of SDOH. Among the 9.5 million Texans who screen positive for unmet social needs, the percentage is higher for the Medicare and Medicaid populations; however, the percentage for those with commercial insurance is not insignificant. Among those with employer-provided health insurance, 25% report unmet social needs.3 To address this need and possibly achieve cost savings, many private payors are surveying their beneficiaries for SDOH. Others are pushing for greater identification through the creation of more ICD-10 diagnosis codes for SDOH (referred to as Z codes). Still others are reaching out to community groups to create partnerships to advance population health management (PHM).

What are the opportunities for radiology? First, we need to recognize the role of SDOH on health and have the confidence to engage in conversations with policymakers. We are already active in PHM. In my May 2018 Bulletin column, I wrote about the opportunities that screening studies afford us and about better surveying patient medical needs.9 How about also screening for unmet social needs? Such discussions are not always easy, as they can be very personal — and sometimes uncomfortable — issues for our patients. Affected individuals may be hard to reach in general, but the gains are worth the effort.

Government and private payors are increasingly reaching out to community organizers to create shared opportunities. How can we engage in those collaborations? What is the role of innovation here? Are there opportunities within digital health to improve access, diagnosis, and treatment of disease, while being mindful not to widen health disparities? There are many questions to be answered — and much insight to be gained.

By Ezequiel Silva III, MD, FACR, Chair

1. Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings:
relationships between determinant factors and health outcomes.
Am J Prev Med. 2016;50(2):129–135.
2. World Health Organization. Social determinants of health. 2012.
3. Berkowitz SA, Hulberg AC, Standish S, et al. Addressing unmet basic
resource needs as part of chronic cardiometabolic disease management.
JAMA Intern Med. 2017;177(2):244–252.
4. Kaiser Family Foundation. Health insurance coverage of the total
population – Texas. 2017.
5. Coleman-Jensen A, Gregory C, Singh A. Household food security in the
United States in 2013. USDA Economic Research Service. 2014.
6. CMS. Medicare provider utilization and payment data: inpatient.
Updated Aug. 28, 2019.
7. Pifer R. ‘Stay tuned,’ says Azar: CMMI to take a closer look at social
determinants of health. Healthcare Dive Web site. 2018.
Accessed Sept. 22, 2019.
8. CMS. Where innovation is happening. Accessed Sept. 22, 2019.
9. Silva E. The economics of PHM. ACR Bulletin. 2018.
Accessed Sept. 22, 2019.

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