Social Determinants of Health - What are Payers Doing?

Social Determinants of Health (SDOH) was a bleeding-edge concept 20 years ago but today, healthcare payers and providers are starting to incorporate SDOH factors to predict the impact on an individual’s health. SDOH are activities or circumstances that are part of your holistic person that a doctor may not consider but are critical in determining the state of your health. According to the CDC, there are five factors that contribute to a person's state of health:

  • Biology and genetics such as sex and age
  • Individual behavior such as alcohol use, smoking, drug use, and unprotected sex
  • Social environment such as gender, income, discrimination factors
  • Physical environment that includes where a person lives and what the living conditions are
  • Health services such as access to healthcare and having or not having health insurance

Social Determinants of Health

In fact, researchers have estimated that your overall health is determined by individual behavior (40 percent), genetics (30 percent), social circumstance (15 percent), environmental factors (5 percent), and healthcare (10 percent).1

Determinants of Overall Health

For all these reasons, payers and providers must evaluate the holistic patient case, which includes social determinants, and not just treat the immediate patient condition.

Payers Focused on SDOH

The healthcare ecosystem continues to operate in silos, with interoperability an ongoing challenge. Data does not flow freely between payers, providers, members/patients, and community resources that can address social factors directly on the ground. The good news is that innovative partnerships are showing the way for both payers and providers. Here are some examples:2

  • Anthem launched a partnership program — Take Action for Health — with the National Urban League, City of Hope, and Pfizer to improve breast cancer and heart disease care in African American communities nationwide.
  • Humana launched an initiative to build community trust, establish behavior change, lower costs, and improve health in seven communities. By 2020, the Bold Goal initiative plans to improve health in these communities by 20 percent.
  • Kaiser Permanente is advancing a “Total Health” framework to address the social determinants of health in neighborhood and school settings that focus on health-promoting policy, system, and environmental changes. To accomplish this, Kaiser Permanente is screening patients for unmet social needs to refer them to relevant resources in their communities. Data shows that 78 percent of those screened have one or more unmet social needs.
  • Harvard Pilgrim launched a program to reduce racial and ethnic disparities in colorectal screening, reducing the screening gap between low-health literacy groups and their general patient population from 11 to 4 percent in four years.
  • UnitedHealthcare Community Plan of WI invested $25,000 in four different community programs that were designed to improve financial independence or interpersonal disability care. The payer also used demographic data to improve the distribution of healthy food to local communities by 87 percent in 2016.
  • Using geospatial data, California-based Health Net reduced postpartum care disparities by 40 percent and increased postpartum visits for African American women in Los Angeles from 17 to 33 percent.
  • CareSource launched a pilot program in three states to help members get and keep jobs that can improve their lives. Among other activities, the program addresses education and skill gaps and links members with employer partners and life coaches.
  • UPMC Health Plan partnered with the Pittsburgh-based Community Human Services to secure permanent supportive housing and provide care coordination for homeless individuals. Those who gained housing saw an average annual health savings of $6,384.
  • L.A. Care Health Plan committed $20 million over five years to fund an initiative to secure permanent supportive housing for homeless individuals in Los Angeles County.
  • Molina Healthcare opened a resource center for homeless members to avoid emergency department use for nonmedical needs. The payer also purchased two behavioral health subsidiaries of Providence Service Corporation to “focus on social determinants of health,” and launched a clinical setting — WellRx pilot in New Mexico — to screen patients for nonmedical social needs.
Care Collaboration Success

Insurers, providers and community resources all have their own relationships with members, patients and consumers, but rarely do the three collaborate with a unifying mission. Download this eBook for real-world examples of care collaboration success between insurers, providers and community resources that have a positive impact on health outcomes.


Payers and providers now realize that assessing people in a more holistic way can make a huge difference in the health and wellbeing of an individual. To that end, SDOH are becoming as important as medical record information. While many payers are down the road with SDOH, the healthcare community in general still has much work to do. Continued partnerships with community organizations and other payers/providers will go a long way to address SDOH but many payers still lack the technology to reach the goal of incorporating SDOH data into their systems.

HealthRules Payor and GuidingCare offer a complete 360° view of a member so that care managers, providers, and community organizations can work together to provide care coordination that incorporates SDOH.

As a payer organization, are you ready to address SDOH initiatives? If not, it’s time to get ready!


Determinants of Health and Their Contribution to Premature Death.  Adapted from McGinnis et al.  Copyright 2007 Massachusetts Medical Society.  All rights reserved.

Unless otherwise noted, most of the payer examples listed are discussed in greater detail in America’s Health Insurance Plan’s (AHIP) article, Beyond the Boundaries of Health Care: Addressing Social Issues.


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