Addressing social determinants of health: Challenges and opportunities in a value-based model

Two forces are reverberating within the US health care system. The first is the medical system’s recognition that addressing a patient’s social circumstances is necessary to promote health and prevent disease. Pediatrics has long espoused the strong influence of family and social conditions on children’s wellbeing. The second force is movement away from fee-for-service reimbursement to a value-based model in which payment is based on quality measures and health outcomes. This value-based system, which was first tested in private insurers and Medicare, has now been extended into Medicaid, which is the largest insurer of US children. By 2020, accountable care organizations (ACOs) will cover 100 million Americans.

These forces’ convergence is influencing Medicaid-related health policies. Medicaid managed-care-organization programs in 30 states are encouraging screening for social needs and providing referrals for social services. Some statewide Medicaid ACO programs require social determinants of health (SDoH) interventions (eg, housing programs) and include health-related social-need screening as a quality measure. The Center for Medicare and Medicaid Services (CMS) also recently announced the Integrated Care for Kids Model, a child-centered service delivery and state payment model that is aimed at reducing expenditures and improving quality of care for children through the prevention, early identification, and treatment of behavioral and physical health needs. The opportunity to engage the health care system with nonmedical sectors (eg, human services, education, and job training) to achieve the Triple Aim (higher quality care, lower per capita cost, and improved population health) and promote health equity is evident. However, key challenges remain.