Addressing social needs requires good evidence

By Austin Frakt

As I read more of the social determinants of health-related literature, I’m noticing a frequent theme: we don’t have enough information to guide decision making.

For example, Kali Thomas and colleagues interviewed representatives from 17 Medicare Advantage plans (collectively capturing 65 percent of the Medicare Advantage market) about the importance of addressing social determinants of health (though they really mean “social needs” —  this is an important distinction.)

Under the 2018 Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act, MA plans can offer supplemental benefits for services that aren’t themselves health care but that “have a reasonable expectation of improving or maintaining the health or overall function.” These could include meal delivery, cooking classes, or home modifications.

As we heard from participants, there is limited evidence to guide plans in determining the best way to meet their members’ needs, including which, how, and for whom interventions work. […] If plans cannot evaluate impact, then resulting cost savings, quality improvement, and member satisfaction will not be well understood.

Among the information plans lack for decision making is that pertaining to financial return on investment (ROI). As one interviewee stated,

It’s all tied to ROI. […] [W]e can’t just spend money without justifying it through savings in some way.

One can certainly argue that from a societal point of view, some things that don’t yield a positive financial ROI should be done anyway, because they improve health and well-being. What MA plans representatives are saying, though, is that they don’t even have good information on that, plus ROI is an issue for them.

Last year, Len Nichols and Lauren Taylor proposed an approach to financing investments in social needs. I mention their paper not to describe the details of the approach (for that, read the paper), but to point out that it relies on the same kind of information that the MA plan representatives found lacking. High-quality data on the effects of most interventions are not readily available. And estimates of financial ROI are needed for any organization to assess the financial feasibility of investments.

These are by no means the only barriers to addressing social needs. In a commentary on screening for them, Karina Davidson and Thomas McGinn, point to several other issues. Among them:

• Screening for social needs would take clinicians’ time away from attending to medical care needs.
• Many physicians lack confidence in addressing social needs. They may be reluctant to screen for them if they don’t know what to do about them.

There are potential solutions to many of these issues, but some will take time to develop. In particular, conducting research to assess the effectiveness of various interventions and their ROI is a multi-year investment.