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
Measure |
SDOH Factor |
Impact |
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Economic Stability |
|
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Food |
|
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Neighborhood & Physical Factors |
|
|
Education |
|
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Community & Social Context |
|
|
Healthcare System |
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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.