The Effectiveness and Cost-Savings of Addressing SDoH
By Jayme Ambrose
As of January 1, 2024, the Centers for Medicare and Medicaid Services (CMS) began requiring healthcare organizations to screen for five social risk drivers, a voluntary task in 2023.
The required five Social Determinants of Health (SDoH) domains are food insecurity, interpersonal safety, housing insecurity, transportation insecurity, and utilities. In 2024, CMS is also introducing two new inpatient quality reporting measures: SDoH screening and the positive rate for SDoH screening to assess how many patients aged 18 and older were screened for the required social risk drivers.
Multiple tools exist that healthcare providers can use to assess patients’ SDoH. Unfortunately, each data set collected is incompatible with others, and the onus to collect the data lies on the shoulders of healthcare providers whose priority is delivering patient care, not collecting data.
The impact of SDoH
Anecdotal evidence shows that addressing social determinants such as food insecurity and housing instability can improve medication adherence. Tailoring interventions and follow-up care based on individual patient needs enhances adherence to treatment plans and reduces healthcare utilization.
A study cited by the National Academy of Medicine found that medical care only accounted for 10%–20% of the contributors to people’s health outcomes.
By contrast, SDoH play a much more significant role in influencing a person’s health, making up 80%–90% of the contributing factors. For example, individuals with limited access to nutritious food or safe housing are at a higher risk for health issues like obesity, diabetes, and heart disease. Based on the principles of Maslow’s hierarchy of needs, safety and security concerns would outweigh an individual’s ability to focus on health concerns such as BP monitoring or self-screening for blood glucose levels.
Collecting SDoH risks is beneficial for understanding the needs of the patients. Assessing the whole patient, which includes the socio-economic components, allows for a greater understanding of their ability to adhere to treatment regimens and/or self-care plans. Working with the patient to successfully address the identified social risks can be very daunting but creating an improvement in quality of life is necessary in order to generate results that improve individual health. Although we assume that addressing SDoH are beneficial, there is limited impact data or significant comprehensive studies validating overall effectiveness, outcomes, and cost-reduction at scale.
Expanding the role of care management
Adobe Population Health, a comprehensive care management company offers proactive care management services through a tech-enabled, hybrid care model delivering whole-person care.
Adobe conducts an SDoH risk assessment of each patient, then determines the resources available in their community by pulling information from a public, private, and non-profit provider database that aligns with the patient’s SDoH risks. Adobe then intervenes to help the patient implement the resources, removing this burden from healthcare providers. In doing so, Adobe gathers a complete picture of at-risk members by combining proprietary risk stratification and health risk assessments with virtual and in-home care delivery with a practical approach to addressing social determinants.
Adobe population health two-year SDoH study
Adobe recently released a study reviewing two years of data collected on their Medicare member population across a state-wide catchment area in the Southwestern U.S. The study involved a statistically significant sample size of targeted interventions impacting 2,355 individuals.
The analysis reviews a year of claims data without SDoH intervention and another full year following when the SDoH risk was addressed to determine if a significant impact could be identified in terms of:
- General demographics
- Total inpatient visits
- Total cost of care (based on claims cost)
- Care gap closures around common but significant chronic conditions like heart disease and diabetes
Overall, the study found that the annual average healthcare cost reduction per member dropped from $13,500 to just under $9,500. Providing a 31% reduction in average healthcare costs.
By gender, the average cost of a male was reduced from approximately $14,500 to approximately $10,500—a 39% reduction. Female average cost dropped from nearly $13,000 to just over $8,500—a 27.8% reduction.
Moreover, health prevention compliance improved dramatically. Blood pressure monitoring improved by 95%, and diabetic screening improved by 47%.
These reductions were achieved by addressing SDoH using Adobe’s proprietary database MASLOWä, which automatically geolocates localized social support resources for food, shelter, transportation, mental health, and other services personalized to the subject’s needs. Adobe social workers then work with members to ensure those concerns are addressed. This information is retained in the Adobe EMR, facilitating rapid report generation, population-level analyses, results measures, and, most importantly, a proactive strategy to remove barriers to care.
Adobe’s care model meets Medicare care management requirements by addressing the SDoH to create customized interventions and significantly reduce costs.
Jayme Ambrose, DNP, RN, CCM, is the founder and CEO of Adobe Care & Wellness, an Arizona-based company offering an innovative, first-of-its-kind solution to the issue of health equity.