Last fall, through an initiative supported by the Aetna Foundation— an independent affiliate of CVS Health—the National Quality Forum (NQF) collaborated with a diverse group of leaders across multiple sectors with the aim to identify quality and payment innovations to systematically address social determinants of health (SDOH).
Indeed, there has been growing recognition over the last several years that a patient’s zip code is a better indicator of his or her health outcomes than a genetic code. Whether it be a lack of access to healthy food, or the limited availability of transportation to care, these, among other socioeconomic circumstances, can shape health inequities and impact as much as 60 percent of health outcomes, according to NQF.
As such, NQF and the many different organizations that it convened last fall—including Aetna, Humana, Lyft, and the American Hospital Association, to name a few—worked collaboratively on strategies to better address SDOH. NQF leaders firmly believe that “addressing SDOH will require transparency, cooperation, inclusion, and shared priorities across the nation at all levels.” Together, the organizations produced a set of recommendations, urging the broader healthcare community to:
- Align policies, funding, and reimbursement across private and public organizations.
- Develop key sets of measures to effectively incorporate and align social determinant of health measurement and activity across the health ecosystem.
- Execute the recommendations from the National Quality Partners Social Determinant of Health Data Integration Action Team.
- Provide funding to test, collect data, assess, and measure the feasibility and effectiveness of community-based SDOH models and targeted interventions designed to maintain or improve health outcomes.
- Incentivize and reward healthcare organizations at multiple levels, including at the front-line and system level, to address social determinants of health gaps, reduce disparities, improve health, and achieve equity. Incentives may include payment, contracting, and non-financial rewards.
Recently, Healthcare Innovation caught up with Shantanu Agrawal, M.D., NQF president, and CEO, and Garth Graham, president of the Aetna Foundation, to discuss the Call to Action, the challenge the industry has had in integrating SDOH, what evidence is needed to accelerate things, how state and national policies play a role, and much more. Below are excerpts of that discussion.
Why has the industry, in your opinion, traditionally been slow to properly address SDOH?
Graham: The issue related to SDOH has been around for a long time and part of the challenge has been figuring out where the traditional health-related levers can play a role. We have found that for the most part, you have to go outside just what happens in the physician’s office and start to think about all these other community factors that impact health. It’s a broader challenge for healthcare because most of the usual levers that we use have not been readily available and accessible in general, since people are used to the kinds of things that occur in clinical encounters, not the other [factors] in people’s lives. That said, folks have been investing in affordable housing for decades. The link was made even before the SDOH as a policy terminology rose to the field, and a lot of us have been on the front lines investing in these kinds of things.
Agrawal: It has taken some time for the healthcare community to develop the right evidence base for which interventions work from a healthcare perspective. Garth is correct in that there has been a lot of data on social risk factors and how they contribute to social and health outcomes. But really knowing which interventions work has taken some time to develop evidence around.
Healthcare has, until the last decade, been paying strictly on a fee-for-service model, and as we move to population-based and value based approaches, there will be a real incentive to address health as a whole—not just healthcare. And that has opened the door to new payment models that can also incentivize providers to address SDOH. It is that opening that we want to take advantage of and understand via this project.
To that end, since incorporating SDOH clearly doesn’t mesh well in a fee-for-service payment system, how challenging is it for organizations that still might primarily be operating within these business models?
Agrawal: It’s an enormous challenge. We tend to see the organizations that are really taking the lead doing so because they are very mission-driven—it’s core to their construct of future healthcare that they will address SDOH—or that they are very vertically integrated, meaning they are a health system that is also a payer. Kaiser Permanente is a good example of that; their financial incentives are already aligned to address social determinants. For this to impact healthcare more broadly, population-based reimbursement models have to come further along so that providers are literally being incentivized to think creatively about intervening in these social risk factors, and then putting resources against that. We need to take advantage of the areas in which we see progress occurring today, learn from early adopters, and think about how to universalize this through other payment approaches.
Graham: Part of this effort has been about pulling others on board, such as community-based organizations (CBOs). Part of what we are trying to establish with this Call to Action and other activities is how to create the right ecosystem so that all these other players are involved. Things have already changed so much [in regard to convening with stakeholders who have not been part of the historical healthcare picture] that we already work with a lot of the folks who are out in the community building networks and an infrastructure.
Agrawal: It’s extremely critical to have community-based organizations and others at the table working to design solutions with more traditional healthcare entities. One thing we have heard jointly through this project, and others, is that while CBOs have clearly been out there doing this work and addressing social issues, the kinds of resources we are talking about mobilizing can all too easily overwhelm these [types of organizations]. So I think we have to be really thoughtful to make sure that the players who have been in this space, and have made important progress, are not overwhelmed by the healthcare approach.
What is the evidence-based path to truly advance SDOH? Can the clinical side of healthcare serve as a framework for success?
Agrawal: For some social determinants, you won’t need the big clinical trials to know it works because it’s logical. If a patient cannot get to an appointment to see a doctor, then solving the transportation need is common sense. There are solutions available today that I would put in the bucket of ‘common sense solutions’ that we should be implementing.
Where evidence may be needed is in more complex scenarios. What kind of food-prescribing approach really works? How do you get together with CBOs, and who plays what role in order to make sure that interventions will succeed? There will be more complexity down the line; some of it around evidence generation, but also just understanding what good implementation looks like. I suspect this will be necessary so that more delivery systems and payers get on board.
Graham: Even in the traditional way in which evidence-based guidelines get adopted, there is a tremendous amount of lag time between clinical guidelines getting [developed] and when they truly make their way to the front lines. And that’s about practice-changing behavior. There is a difference here since people on the front lines are already doing a lot and have been seeing the nuances of how engagement works. So I’m not sure you will need the same amount of time [with SDOH] since there has already been a lot of momentum.
How would you qualify state and national policies today, in terms of their ability to address SDOH?
Graham: We have a smorgasbord of progress as well as places where we need more progress. Medicare has opened up support for these kinds of services, and Medicaid traditionally has, too. We have been doing a lot of work in the commercial space addressing this with large employers, and what you find is a vast array of policies that can move SDOH forward—and that’s just not on the payment side, but zoning and housing, such as how people can access affordable housing in certain neighborhoods. As a country, it’s a mixed picture.
Undoubtedly, there has been a lot of positive momentum as it relates to SDOH. Looking into the proverbial crystal ball, what might this all look like in three to five years?
Graham: The hope is that it will be very different, and that this effort and others will spur change.
Agrawal: There has been a lot of heterogeneity among health plans and states, and I think in five years we will see more states follow the lead of a state like North Carolina. They will realize that this is the right thing to do from a population-based standpoint, and from a public sector view. So I think we will see a lot more states adopt new payment methodologies, and allow for more liberal payment approaches so providers can cover these kinds of issues.
I think health plans will be in the same place, and in working with large delivery systems, everyone sees the logic of early intervention. They see that you can generate a return on these kinds of investments, and as more providers get into population-based payment models, this will be very logical step for them early on. I expect them to generate a lot of return, perhaps even more so than spending a lot of resources on advanced-age chronic illnesses.
