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SDoH Blog Series | Part 3 of 3: Social Determinants of Health - Quality Management in Healthcare

doctors and manager having discussion

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

In Part 2 of the SDoH blog series, we highlighted the major action plans and initiatives undertaken by various payer organizations to address social determinants risks for members. The final blog shares the role of SDoH in the context of quality management and its impact on HEDIS and STAR rating measures.

SDoH plays a major contributor to determine the member health ratio of 80:20 (80% by non- clinical factors and 20% is determined by clinical measures), and plays a vital role in determining the quality of care for a member.

To understand the member health ratio, let’s take an example of Peter, who is experiencing anxiety and hypertension and decides to visit a physician:

  • Peter takes an appointment and visits a physician
  • Upon examination of his clinical condition, the physician prescribes medication. But the physician did not enquire about non-clinical factors which may also have contributed to Peter’s condition
  • If non-clinical factors are obtained, then members can be referred to different community-based programs or they can be offered services as per their SDoH needs

This would not just help manage member health, but will help providers and payers to improve on quality measures.

A recently conducted research suggests that health plans that improved on measures after addressing social determinants gained higher proportion of new enrollees.

Health plans also successfully retained their existing membership. Capturing SDoH data efficiently will enable providers get better patient insights for prescribing the appropriate course of treatment. This would result in higher quality of treatments and better incentives.

Therefore, incorporating accurate socioeconomic data in HEDIS and STAR can be beneficial across a vast range of health risks such as comprehensive diabetes care, controlling high blood pressure, pharmacy and behavioral health. It will allow organizations to identify the gaps in network performance such as patient follow-up patterns, vaccinations, screenings, drug testing, etc.

Impact of SDoH factors on HEDIS and STAR rating measures


SDOH Factor


  • HEDIS - Comprehensive Diabetes Care (CDC)
  • STAR Rating Measure – Diabetes Care: Blood Sugar Controlled

Economic Stability

  • Low-income groups find it difficult to opt for healthy meals, regular medical appointments, and lab tests
  • Unemployed people are more likely to report fair / poor health, and are at a higher risk of acquiring stress-related conditions such as diabetes, heart diseases, etc.
  • If the SDoH risk associated with a member is identified at the point of care or during enrollment, then the member can be referred to community-based program or given the benefit as per socio-economic need
  • This can help reduce the chances of acquiring chronic diseases and improve the mortality rate reported due to Diabetes
  • HEDIS - Controlling High Blood Pressure (CBP)
  • STAR Rating Measure - CBP


  • Food insecurity leads to high BP, hypertension, and other chronic diseases across generations
  • When members don't have access to healthy meals, they use coping strategies, shifting their dietary intake to unhealthy food which impacts their health and results in various chronic diseases such as obesity, high bp, heart disease, diabetes, etc.
  • HEDIS - Adult BMI Assessment (ABA)
  • STAR Rating Measure (ABA, Incorporating or Maintaining Physical Health & Monitoring Physical Activity)

Neighborhood & Physical Factors

  • Limited access to parks for physical fitness can result in lack of physical activity and have a negative impact on the BMI of members
  • Lack of fitness activities results in obesity which adversely impacts individual health
  • HEDIS - Breast Cancer Screening (BCS) & Colorectal Cancer Screening (COL)
  • STAR Rating Measure - BCS & COL


  • Women may lack basic knowledge on the causes, prevention, diagnosis, early detection by self-examination, and importance of screening methods for cancer
  • Due to lack of knowledge, they don’t participate in screening programs organized by payer and communities, and may increase the risk of cancer
  • HEDIS - Care for Older Adults (COA)
  • STAR Rating Measure - Getting Needed Care

Community & Social Context

  • Loneliness and isolation results in chronic conditions and sometimes increases the risk of death in older population
  • As per CDC Data for Minnesota for the year 2015, it was observed that 56.9 % of Medicare enrolled persons had prevalence of two or more chronic conditions
  • HEDIS - Adolescent Well-care Visits (AWC)
  • STAR Rating Measures - Getting Appointments and Care Quickly

Healthcare System

  • Unavailability of provider / longer wait times for seeking appointments sometimes result in members missing their appointments and opting out of health services
  • As per a data analytics research paper by NCBI, missed appointment rates range from 10% to 50% across healthcare settings in the world with an average rate of 27% in North America


A significant number of evidences suggest an association between social determinants of a member and increased utilization of health care services, decreased use of preventive health care services, and poorer health outcomes in adults with chronic diseases. These findings give a clear picture on the impact of non-clinical factors on the quality and outcomes of health care and provide an impetus to identify individuals with SDoH risk for targeted interventions.

To achieve this, skilled care managers are required to capture all the details on socio-economic factors. SDoH data capture is still a challenge for providers as well as payers. For SDoH, there isn’t any concrete data source available, except Claims. To gain a better insight into member’s profile, payers often have to connect with third parties such as credit bureaus, transportation department and data aggregators as well. CitiusTech believes that there is a need of concrete policies and IT arrangements to have the socio-economic data at a centralized location to improve the SDoH risk associated with a member and help them stay healthy.

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