Tackling Root Causes: Screening and Addressing Non-Medical Drivers of Health

Overview

Non-medical drivers of health, also known as social determinants of health (SDOH), are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”[1] These factors play a significant role in individuals’ health outcomes, thus in a holistic model of health care delivery it is critical to address these influencers of health.[2] Primary care physicians (PCPs) are uniquely positioned to identify SDOH and connect patients and families with suitable resources. Unfortunately, few PCPs are able to screen and refer those in need due to a lack of clinic-based services. It is vital to include mechanisms in reimbursement systems to support providers in creating infrastructure that can meet the essential needs of patients.

Scope of the Problem

Social determinants of health affect a substantial portion of the population and are known to have serious health implications for individuals and communities. Patients with unmet SDOH are unhealthier, and at risk for more medical problems.[3] For example: 

• Patients are more likely to have depression, diabetes, and hypertension.[4]
• In patients with Type 2 diabetes, SDOH were found to have a negative impact on glycemic control, cholesterol, and blood pressure.[5]
• Patients with housing insecurity were associated with increased rates of COVID-19 — housing insecurity and poor housing conditions have also been linked to asthma and increased risk of respiratory infections.[6] 

Moreover, pediatric populations are especially at risk. Among a pediatric population where roughly 84% were covered by Medicaid, 25% to 30% of families had concerns about unmet social needs, with financial resource strain, housing instability, and food insecurity being the primary issues.[7]

Food Insecurity Has Myriad Effects

Food insecurity in children has been associated with considerable long-term health problems.[8] It increases the risk of asthma, particularly in impoverished households, and is linked to poor nutrition and other respiratory illness risk factors.[9] Additionally, it can lead to developmental delays, behavioral problems such as anxiety and impaired social skills, weakened immune responses, and a higher likelihood of hospitalization. Persistent food insecurity into adolescence is also correlated with chronic adult diseases like Type 2 diabetes and cardiovascular disease.[10] In addition, food and housing insecurity have been shown to negatively affect medication compliance.[11]

Difficulties Around Accessing Medical Services

How patients access preventive medical services and how health care is delivered are also affected by social factors. Patients with unmet social needs are more likely to be frequent emergency department (ED) users and frequent “no shows” at clinic appointments.[12] Lack of transportation, lack of insurance, poor health literacy, and language barriers were reported as the biggest barriers to receiving timely cancer screenings and have negative consequences for cancer health equity.[13]

Identification and Triage

Recognizing the primary needs of a community and establishing an infrastructure with supportive systems for referrals are essential elements in shaping health outcomes. To effectively identify and triage SDOH, it is crucial to implement universal screening protocols and develop responsive systems for individuals in need of assistance. A comprehensive approach requires multidisciplinary teams comprising community health workers (CHWs), social workers, nurses, and healthcare professionals. The screening and navigation process must encompass: 

1. Administration of SDOH screening before or during each health supervision visit (at least). 
2. Documentation via electronic health record (EHR).
3. Referral to community resources or social services based on needs identified via screening.
4. Case management to follow-up on identified needs and referrals.
5. Data reporting and quality improvement. 

Spending Differently and Spending Less

Dealing with SDOH can markedly change the way health care dollars are spent and decrease overall costs. In federally qualified health centers (FQHC) — community health centers — the ongoing screening, referral, case management, and quality improvement activities were estimated to cost from $11,710 to $40,032, equivalent to $9.76 to $47.98 on a per-patient basis, depending on the patient volume.[14] This is much lower than ED visits for which costs average thousands of dollars per visit.

A review by the Commonwealth Fund revealed that various health-related social needs interventions generated a positive return on investment (ROI).[15]

• Housing assistance programs reduced ED visits, admissions, and health care costs, while increasing use of preventive primary care services.[16] 
• Access to healthy food via home-delivered, medically tailored meals significantly lowered health care utilization and costs, especially among those with chronic conditions or at nutritional risk.[17]

Care management programs that incorporated multidisciplinary teams and connected patients with community resources for social needs demonstrated reduced ED visits, hospitalizations, and positive ROI.[18] Community health worker interventions for depression and unmet social needs demonstrated health care cost savings and improved health outcomes among high-cost populations — they also reduced readmissions and missed outpatient visits 30 days post discharge from hospital.[19] Addressing SDOH can improve the health of patients while also improving health care delivery systems and reducing costs.[20]

Existing Policies 

In July 2023, the Centers for Medicare and Medicaid Services (CMS) released the 2024 Medicare Physician Fee Schedule.[21] The primary focus was to promote health equity and patient-centered care, which involved coding and compensation strategies for covering SDOHs. This enhancement ensures better support for initiatives across hospitals, clinics, and community settings. It also complements the Health and Human Services (HHS) Social Determinants of Health Action Plan, which strategizes the integration of health and human services to manage SDOH more effectively.[22]

Additionally, a report from the Physician-Focused Payment Model Technical Advisory Committee: 

• Championed payer models that factor in SDOH when compensating providers who care for high-risk populations. 
• Endorsed the provision of upfront, flexible, and sustainable funding to effectively deal with individual patient SDOH needs.[23]
• Emphasized that properly addressing SDOH can lead to a reduction in hospitalizations and ED visits, cutting overall health care costs.[24]

In 2024, CMS will require inpatient facilities to screen patients with Medicare for five social domains — housing instability, food insecurity, financial insecurity, transportation issues, and utility assistance — via coding or hospital quality reporting.[25]

At a state level, the 88th Texas legislative session passed HB 1575, which requires Texas Medicaid to develop a standardized, strengthened screening tool to help determine the non-medical health needs of pregnant Texans and their babies.[26] It also allows CHWs and doulas to be reimbursed by Medicaid, through the state’s Case Management for Children and Pregnant Women program, for their work on these important needs. This marks a significant stride in mitigating the key factors influencing health, however it is just one step toward full closure of the gap in care.

Areas that continue to lack adequate reimbursement include these programs: 

• Principal illness navigation services help people with Medicare who are diagnosed with high-risk conditions (e.g., mental health conditions, substance use disorder, and cancer) identify and connect with appropriate clinical and support resources.
• Community health integration services seek to address unmet SDOH needs that affect the diagnosis and treatment of the patient’s medical problems.

It is imperative that CMS determines how to pay for the time practitioners spend screening and navigating resources for SDOH needs — such as financial, transportation, and social — that impact their ability to treat the patient.

Policy Recommendations

Social determinants of health wield significant influence over patients' well-being and substantially impact the effective delivery of health care. To transform patient care and bolster health care systems in enhancing population health, the following policy priorities are recommended:

• Implement and fund the current CMS recommendations for screening populations and providing referrals.
• Support primary care providers to screen patients for SDOH.
• Enable the creation of referral services to respond to patients who report a need. 
• Work with payers to incentivize SDOH screening and resource navigation.

Notes

[1] “Social Determinants of Health at CDC,” Centers for Disease Control and Prevention, last reviewed December 8, 2022, https://www.cdc.gov/about/sdoh/index.html. Social determinants of health (SDOH) is the term used in the literature, while in Texas these factors are referred to non-medical drivers of health (NMDOH).

[2] “Social Determinants of Health,” World Health Organization — Global, accessed December 4, 2023, https://www.who.int/teams/social-determinants-of-health.

[3] Elissa M. Abrams et al., “The COVID-19 Pandemic: Adverse Effects on the Social Determinants of Health in Children and Families,” Annals of Allergy, Asthma & Immunology 128, no. 1 (January 2022): 19–25, https://doi.org/10.1016/J.ANAI.2021.10.022.

[4] Seth A. Berkowitz et al., “Addressing Basic Resource Needs to Improve Primary Care Quality: A Community Collaboration Programme,” BMJ Quality & Safety 25, no. 3 (February 2016): 164–72, https://doi.org/10.1136/BMJQS-2015-004521.

[5] Rebekah J. Walker et al., “Impact of Social Determinants of Health on Outcomes for Type 2 Diabetes: A Systematic Review,” Endocrine 47, no. 1 (February 2014): 29–48, https://doi.org/10.1007/S12020-014-0195-0.

[6] Abrams et al.

[7] Kaitlin Stark et al., “Evaluation of a Clinic-Based, Electronic Social Determinants of Health Screening and Intervention in Primary Care Pediatrics,” Academic Pediatrics 24, no. 2 (March 2024): 302–8, https://doi.org/10.1016/j.acap.2023.12.010.

[8] Margaret M.C. Thomas, Daniel P. Miller, and Taryn. W. Morrissey, “Food Insecurity and Child Health,” Pediatrics 144, no. 4 (October 2019): e20190397, https://doi.org/10.1542/PEDS.2019-0397.

[9] Abrams et al.; Thomas, Miller, and Morrissey.

[10] Abrams et al. 

[11] Marcee E. Wilder et al., “The Impact of Social Determinants of Health on Medication Adherence: A Systematic Review and Meta-Analysis,” Journal of General Internal Medicine 36 (January 2021): 1359–70, https://doi.org/10.1007/S11606-020-06447-0.

[12] Berkowitz et al. 

[13] Shaheen S. Kurani et al., “Association of Neighborhood Measures of Social Determinants of Health With Breast, Cervical, and Colorectal Cancer Screening Rates in the U.S. Midwest,” JAMA Network Open 3, no. 3 (March 2020): e200618, https://doi.org/10.1001/JAMANETWORKOPEN.2020.0618; Scarlett Lin Gomez et al., “The Impact of Neighborhood Social and Built Environment Factors across the Cancer Continuum: Current Research, Methodological Considerations, and Future Directions,” Cancer 121, no. 14 (July 2015): 2314–30, https://doi.org/10.1002/CNCR.29345; Kassandra I. Alcaraz et al., “Understanding and Addressing Social Determinants to Advance Cancer Health Equity in the United States: A Blueprint for Practice, Research, and Policy,” CA: A Cancer Journal for Clinicians 70, no. 1 (January/February 2020): 31–46, https://doi.org/10.3322/CAAC.21586; and Laura Marlow et al., “Barriers to Cervical Screening among Older Women from Hard-to-Reach Groups: A Qualitative Study in England,” BMC Women’s Health 19, no. 1 (February 2019): 1–10, https://doi.org/10.1186/S12905-019-0736-Z.

[14] Connor Drake et al., “The Direct Clinic-Level Cost of the Implementation and Use of a Protocol to Assess and Address Social Needs in Diverse Community Health Center Primary Care Clinical Settings,” Journal of Health Care for the Poor and Underserved 32, no. 4 (November 2021): 1872–88, https://doi.org/10.1353/HPU.2021.0171.

[15] Douglas McCarthy et al., “Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update,” The Playbook Implementation Tool, September 2022, accessed December 4, 2023. https://bettercareplaybook.org/resources/guide-evidence-health-related-social-needs-interventions-2022-update.

[16] Ellen Robin Embick et al. “Demonstrated Health Care Cost Savings for Women: Findings from a Community Health Worker Intervention Designed to Address Depression and Unmet Social Needs,” Archives of Women’s Mental Health 24 (February 2021): 85–92, https://doi.org/10.1007/S00737-020-01045-9.

[17] Embick et al.

[18] Embick et al.; Jocelyn Carter et al., “Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population: A Randomized Clinical Trial,” JAMA Network Open 4, no. 5 (May 2021): e2110936, https://doi.org/10.1001/JAMANETWORKOPEN.2021.10936.

[19] Embick et al.

[20] Carter et al.

[21] “Physician Fee Schedule,” Centers for Medicare & Medicaid Services, last modified March 18, 2024, https://www.cms.gov/medicare/payment/fee-schedules/physician/.

[22] Department of Health and Human Services (HHS), “Strategic Goal 1: Objective 1.3,” accessed October 23, 2023, https://www.hhs.gov/about/strategic-plan/2022-2026/goal-1/objective-1-3/index.html; Office of the Assistant Secretary for Planning and Evaluation (ASPE), HHS’s Strategic Approach to Addressing Social Determinants of Health to Advance Health Equity — At a Glance, April 1, 2022, https://aspe.hhs.gov/sites/default/files/documents/aabf48cbd391be21e5186eeae728ccd7/SDOH-Action-Plan-At-a-Glance.pdf.

[23] ASPE, “Physician-Focused Payment Model Technical Advisory Committee (PTAC), accessed December 4, 2023, https://aspe.hhs.gov/collaborations-committees-advisory-groups/ptac.

[24] PTAC.

[25] Hannah P. Truong et al., “Utilization of Social Determinants of Health ICD-10 Z-Codes among Hospitalized Patients in the United States, 2016–2017,” Medical Care 58, no. 12 (December 2020): 1037–43, https://doi.org/10.1097/MLR.0000000000001418.

[26] An Act Relating to Improving Health Outcomes for Pregnant Women Under Medicaid and Certain Other Public Benefits Programs, H.B. 1575, 88th Texas Legislative Session, (20233), https://capitol.texas.gov/tlodocs/88R/billtext/html/HB01575H.htm.

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