Payment Structures That Support Social Care Integration With Clinical Care: Social Deprivation Indices and Novel Payment Models

Abstract

The U.S. lags behind other developed countries in the use of indices and novel reimbursement models to adjust for social determinants of health (SDH) in medicine. This may be due in part to the inadequate body of research regarding outcomes after implementation of healthcare payments designed to address SDH. This perspective article focuses on four models employed both internationally and domestically to outline the implementation, successes, limitations, and research needed to support national application of SDH models. A brief history of prior models is introduced as a primer to the current U.S. system. Internationally, the United Kingdom and New Zealand employ small area indices to adjust healthcare dollar allocation based on increased social need in an area. Despite published evidence of disparate health outcomes based on SDH, research is limited on the association of SDH indices, subsequent increased reimbursement, and improved healthcare equity. In the U.S., the Massachusetts Managed Care Organization assesses and addresses social needs within communities served by Medicaid. Unsurprisingly, there is evidence of overlap between those with worse health outcomes and those with high social need. However, implementation in Massachusetts is too recent to demonstrate reduced healthcare disparities. Within Minnesota, Hennepin Healthcare System initiated a novel Medicaid waiver that provides extended services to high-need patients under a partial capitation reimbursement program. These services, including increased access to primary care, have promising results in financial improvement of the system, but have not yet demonstrated patient-oriented outcomes. The association between high social risk and poor medical outcomes has been established globally; however, healthcare payment policies designed to respond to this relationship generally lack evidence of affecting outcomes. U.S. policymakers are demonstrating increasing interest in requiring capture of SDH in health care, creating accountability for addressing SDH, paying differentially for patients with increased social risk, or all three. In countries with a legacy of adjusting healthcare payments for social risk, more robust evaluation of associated effects could be helpful. Payers, states, or health systems making similar resource commitments should build in robust longitudinal evaluations of outcomes to inform evolution of their payment policies. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.