How are health insurance plans approaching social determinants of health?

Sept. 25, 2020 / By L. Gordon Moore, MD

In some estimates, medical care accounts for approximately 11 percent of a person’s health and wellness; the rest is made up of individual behaviors as well as environmental factors.  When considering ways to improve health outcomes and reduce unnecessary expenditures – key performance indicators for any health plan — it is logical to consider Social Determinants of Health (SDOH).

Since SDOH factors are not the typical sphere of health insurance and health care delivery, questions arise:

  • What is the role of the health plan in addressing SDOH?
  • Should plans provide funds to Community Based Organizations (CBOs)?
  • Which SDOH factors should we address and in what order of priority?
  • Should a health plan provide direct care or support?

As in any complex work, it is helpful to clarify your goals and how you plan to accomplish them. For example:

  1. We want to improve health outcomes and reduce unnecessary health care expenditures.
  2. We will accomplish this by reducing unnecessary hospitalizations.
  3. We will measure success by tracking risk adjusted total cost of care and Potentially Preventable Admissions (PPAs).

Next, line up the interventions likely to achieve the goal(s):

  1. We will identify the member cohorts with the greatest observed-to-expected gaps in PPAs.
  2. We will rank the SDOH factors having the greatest negative impact on these cohorts.
  3. We will identify and partner with the CBOs that work on the most important factors and are co-located with the member cohorts with the identified needs.

It all looks pretty obvious when it’s written out like this, but the lessons learned from health plans and others who have experience with this work provides valuable insight to those just beginning the journey. 

Michelle Jester, the Executive Director of Social Determinants of Health for America’s Health Insurance Plans, describes AHIP’s Project Link – a forum for health plans to share their experiences in the SDOH journey so that all may benefit.  She describes the importance of developing partnerships with CBOs, working to standardize the communication strategies among the stakeholders to reduce the friction of varying approaches (e.g. every hospital system and health plan creating their own list of “please inform us when…”).

Listen to our discussion on the 3M Inside Angle podcast.

L. Gordon Moore, MD, is senior medical director, Clinical Strategy and Value-based Care for 3M Health Information Systems.

Striving to achieve health equity by addressing social and clinical risk.