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SDoH Blog Series | Part 2 of 3: Social Determinants of Health - Role of Payers

By Mamta Joshi, Sr. Healthcare Consultant, Health Plans and Smriti Srivastava, Healthcare Consultant, Health Plans

In Part 1 of the SDoH blog series, we realized the impact of non-clinical factors / social determinants has on member health outcomes. Access to healthy food and a physical environment are one of the major determinants of an individual’s health. Yet, a significant population of members still face obstacles across various social determinants.

To effectively manage the risks associated with social determinants, payer organizations are beginning to engage in activities around improving member engagement, provider engagement, and population health.

Member Engagement

Provider Engagement


Population Health Engagement

  • Member education / coaching on overall wellness
  • Member community assistance around access to healthy diet and transportation and home delivery of drugs / groceries
  • Organization of screenings and vaccination programs
  • Run pilot programs to help members find and retain jobs by addressing employment-related health factors
  • Provider education to improve point-of-care assessment and capture of SDoH data
  • Better provider incentives based on member’s health
  • Behavioral health counseling
  • Community specialists. e.g. reduce social isolation among seniors, better welfare and health policy, and social care referrals



Leading payer partnership programs




UPMC Health Plan

Pittsburgh-based Community Human Services

To secure permanent supportive housing and provide care coordination for homeless individuals


Bold Goal Initiative Plans

Build community trust, establish behavior change, lower costs, and improve health in several communities

United Healthcare

 Community Programs

Improve financial independence / interpersonal disability care, and increase distribution of healthy food to local communities using demographic data



Help members get and keep jobs that can improve their lives. The program addresses education and skill gaps and links members with employer partners and life coaches

L.A. Care Health Plan


To fund an initiative to secure permanent supportive housing for homeless individuals in Los Angeles County


Payers are leveraging predictive analytics to address SDoH risks associated with a member

Big Data and analytics are helping payers to reach members at the right time, through their preferred channels. This level of personalized support is helping payers connect their members with vital resources such as transportation assistance, local food bank information, and behavioral health services. Various predictive analytics and artificial intelligence (AI) tools are helping payers verify patient self-reported SDoH factors, send appointment reminders, and provide additional resources to fill the gaps-in-care.

Payers also plan on leveraging data analytics tools to identify the risks associated with social determinants of members. Availability of accurate data is helping members identify their SDoH needs. Research has indicated that payer efforts are evident and reaping significant benefits as they are helping members achieve better health, while reducing healthcare costs.

For instance, Humana and Aetna are working on the development of ‘loneliness predictive models’ to highlight at-risk members.

Payers follow CMS guidelines to address SDoH

To help members overcome social determinants challenges, the Centre for Medicare and Medicaid (CMS) has provided a few supplemental benefits under Medicare Advantage and Part D plans.

The services offered by CMS under MA and Part D plans include – meal delivery, rides to grocery stores, covering the cost of an air-filter for a patient living with asthma, etc. Other potential benefits which are offered include – healthy food plans, diabetes education, nutrition services, non-emergency medical transportation. It also allows the plan to care for members who may be impacted by opioid crisis. Medicare Part D offers at least one overdose reversal drug on a low-cost sharing tier, thereby improving patient’s access to medication.

As payers are focusing their investments for improving member health, social determinants of health have the potential to improve health outcomes while reducing healthcare costs. Application of advanced analytics and interventions tailored to communities will be key to address the SDoH risks associated with members, and reduce the rate of readmissions.

CitiusTech supports payer organizations data science teams by conducting ‘Innovation Garage’ programs to develop proof-of-concepts for promoting innovation needs and optimizing staff time. This results in healthier and engaged beneficiaries.

In the final part of the blog series, we will highlight the role of Social Determinants in Quality Management.

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