By Mamta Joshi, Sr. Healthcare Consultant, Health Plans and Smriti Srivastava, Healthcare Consultant, Health Plans
Health plans have always relied on data obtained from medical and pharmacy claims, lab records, hospitalizations, and health risk assessments to manage their member population. Lately, health plans are looking beyond these traditional sources of data, and incorporate non-clinical information such as Social Determinants of Health (SDoH) to predict the impact on an individual’s health.
The WHO (World Health Organization) describes Social Determinants of Health as “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. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”
According to CDC (The Centers for Disease Control and Prevention), there are six factors that contribute to person’s state of health:
Sources for Data on SDoH
In addition to obtaining data from clinical workflows, payer and provider systems leverage certain non-traditional sources to obtain SDoH related data. Sources include:
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Organization |
Data Source |
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Payer |
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Provider |
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Capturing SDoH Data for the Healthcare Ecosystem
The National Committee for Quality Assurance (NCQA), Arizona Health Care Cost Containment System (AHCCCS) and the Center for Healthcare Research & Transformation (CHRT) University of Michigan have endorsed the use and expansion of the ICD-10-CM codes to capture SDoH data. Logical Observation
Identifiers Names and Codes (LOINC) have also developed a robust model for representing measures of SDoH and assessments, including questions, answers, and the collection of such variables into forms.
- Economic Stability - ICD-10: Z56 problems related to employment and unemployment, LIONC: 67784-9 individuals in below poverty line neighborhood
- Neighborhood & Physical Factors - ICD-10: Z59 problems related to housing and economic circumstances, LIONC: 46561-7 current ability – transportation
- Education - ICD-10: Z55.0 illiteracy and low-level literacy, LIONC: 82590-1 years of education (#) – reported
- Food - ICD-10: Z59.4 lack of adequate food and safe drinking water, LIONC:88124-3 food insecurity risks
- Community & Social Context - ICD-10: Z60 Problems related to social environment, LIONC:62933-7 PhenX - social isolation protocol 181001
- Healthcare Systems - ICD-10: Z75.3 unavailability and inaccessibility of health care facilities, LIONC:52556-8 payment sources
Benefits
Payers and providers can leverage SDoH data to improve individual health, minimize cost of care, and ensure timely delivery of interventions and services.
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Activity |
Benefit |
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Care Coordination |
If a health plan identifies individuals with a SDoH risk such as food insecurity, then the member can be referred to social / govt. service for easy access to healthy meals. |
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Recognizing Health & Wellness Risks with SDoH Analytics |
Healthcare stakeholders can predict if an individual is at an increased risk of an adverse health outcomes such as being readmitted to the hospital or not adhering to a medication regime. |
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Mapping Community Resources and Identifying Gaps |
Healthcare organizations can identify local community-based services and refer members as per their SDoH need. This helps providers, health plans, and communities build partnership networks. |
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Service and Impact Assessment |
Identifying individuals with SDoH risk at the time of discharge, and taking appropriate actions can help reduce readmission rates. |
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Customizing Health Services and Interventions |
Lack of transportation can prevent members from visiting pharmacies and making follow-up visits. Stakeholders can identify such members and arrange for ride services in advance. |
To Summarize, health plans need to be forward looking and incorporate the concept SDoH into their offerings to foster long-term customer loyalty and increase member outcomes.
Next in the blog series, Part 2: "Role of Payers in SDoH”.
