Predictive value of a financial strain question to pre-screen individuals for social risks

BACKGROUND: Social risks are associated with poor health outcomes and increased costs. Therefore, health systems and policymakers increasingly emphasize social risk screening and interventions. However, universal screening implementation remains challenging due to clinician burnout, lack of evidence, and financial trade-offs. One solution to decrease implementation burden is a two-step social risk screening system where individuals who screen positive for financial strain are then surveyed for other social risks. 

OBJECTIVE: We analyzed the predictive value of a financial strain screener as a pre-screener for food insecurity, housing instability, and/or transportation barriers. 

DESIGN: Longitudinal study evaluating the proportion of participants endorsing financial strain and other social risks. Data obtained from OCHIN (2017-2023), Humana (2019-2020), and Kaiser Permanente (KP) (2020). We assessed the predictive value (e.g., sensitivity, specificity, positive and negative predictive value, and area under the receiver operating characteristic curve) of using financial strain as a pre-screener for the other social risks. 

PARTICIPANTS: The sample included n = 252,845 adults (≥18 years old) with complete data on all four social risks (63.7% from OCHIN, 32.2% from Humana, 4.1% from KP). The response rate varied from 18.7% (Humana) to 23.0% (KP); the OCHIN sample included 21.6% of eligible encounters. 

MAIN MEASURES: Data related to financial strain, food insecurity, housing instability, and transportation barriers were derived from survey responses and visit-level encounter data. 

KEY RESULTS: The OCHIN sample included 38%, Humana 41%, and KP 28% with financial strain. Using the financial strain item in an initial pre-screening would fail to identify 12.3 to 24.2% of individuals who reported food insecurity, 13.2 to 24.7% who reported housing instability, 17.0 to 32.6% who reported transportation barriers, and 4.1 to 5.7% who reported all three risks. 

CONCLUSIONS: A financial strain pre-screener could lead health systems to miss >10% of people who report food insecurity, housing instability, and/or transportation barriers.