Integrating Payer and Provider Data to Address Social Determinants of Health

Integrated delivery and finance systems are a viable option to measure program outcomes when addressing social determinants of health (SDoH) and highlight the potential benefits of payer-provider collaboration, according to a Journal of Managed Care & Specialty Pharmacy article.

Authors referenced an Evolve survey that indicated that 41% of 552 payer and provider respondents cited budgetary constraints and unclear returns on investment (ROIs) as barriers to implementing interventions for SDoH.

ROIs are made uncertain by several factors including difficulty measuring direct benefits (such as prevention of cardiac disease); difficulty reaching short-term financial goals, given the long-term nature of many of these programs; and inclusion of people outside the target population in the beneficiary pool, particularly with communally accessible goods and services. 

Integrated delivery and finance systems integrate payer and provider functions and allow stakeholders to access financial and clinical data to measure the impact of value-based programs more accurately. Value-based programs differ from traditional cost-savings interventions in that they include financial savings associated with improved health metrics in the cost-benefit evaluation. 

Attributes that make integrated delivery and finance systems well suited for implementing SDoH interventions include:

• the integration of payer and provider data, which allows payers to access clinical records and providers to access overall cost data;
• the ability to identify which SDoH traits are associated with high utilization of care, facilitating the process of addressing population needs for the best outcomes; and
• the capacity to pilot programs successfully due to the vertical coordination of administrative, clinical, and financial management of patients, which provides an integrated delivery and finance system with crucial data across multiple stakeholders.

“Although the [Integrated delivery and finance system] structure is not the only system type that allows for evaluation of an ROI for SDoH interventions, it illustrates the potential that arises from the synthesis of payer and provider information and from collaboratively working together to achieve common goals,” authors noted. “Therefore, for nonvertically integrated systems, we urge payers and providers to partner in order to address SDoH, since their strengths compensate for each other’s weaknesses.”

COVID-19 exacerbated the need to address SDoH and improve health policies and systems so that patients can increasingly access high quality care.

“According to the World Economic Forum, 500 million people could fall into poverty, with many more experiencing a drastic drop in income,” authors wrote. “Patients with social determinant-based issues such as homelessness, unemployment, and poor social support are more likely to become infected by COVID-19 and experience severe symptoms and higher mortality rates.”

Interventions to address SDoH-related issues during the pandemic have already been implemented. These include relaxed restrictions for telehealth reimbursement by the Centers for Medicare & Medicaid Services and Blue Cross Blue Shield of Oklahoma’s initiative to provide testing for underserved communities by repurposing its Caring Van fleet, among others.

To limit risk and produce the best outcomes, authors suggested that payers and providers continue to collaborate on addressing SDoH and share their results so that others might learn successful frameworks and identify challenges to program implementation.

“Although there are still many needed efforts to identify the ‘special sauce’ for constructing and demonstrating the value of SDoH interventions, there is exciting work being performed by stakeholders throughout the health sphere to address these challenges via partnerships,” authors wrote. “For now, it remains the next big hurdle to tackle in the evolution of population health.”

Reference:
Kannarkat JT, Hartle JE, Parekh N. Need for payer-provider partnerships in addressing social determinants of health. J Manag Care Spec Pharm, 2021;27(6):791-796. doi:10.18553/jmcp.2021.27.6.791