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By Duane Feger, Acclivity Healthcare Economist
There is consensus in the healthcare community that socioeconomic factors affect the health outcomes of all segments of America’s population. In fact, the U.S. Department of Health and Human Services cites studies indicating up to 50% of the county-level variations in health outcomes are impacted by social determinants of health (SDoH). These social determinants include factors such as access to healthcare and transportation, housing and food insecurity, poverty, illiteracy, poor education, exposure to violence, and isolation.
While health organizations and CMS now recognize the need to address social determinants of health (SDoH), they are challenged by their inability to access appropriate SDoH data. They don’t have the insights to anticipate the socio-economic needs of their patients and adapt care plans proactively. When SDoH data is available, the majority of organizations lack functional partnerships with community-based social services providers who could assist patients who require their support.
While these challenges create obstacles, they are not insurmountable. Using vision and the right set of tools, our healthcare system can address SDoH, reduce disparities in care, significantly improve health outcomes, and reduce avoidable healthcare utilization.
Improving patient population insights
It’s possible to develop a more comprehensive view of patient populations. Two effective strategies include:
1. Use Z Codes to include social needs data to the EHR
Since 2015, any member of a patient’s care team can —and should — add social needs to each patient’s chart with Z codes. Z codes are ICD-10-CM encounter reason codes that track and record high-impact socioeconomic factors that affect health. They provide a standardized approach for screening and collecting information to record what CMS terms “the conditions in the environments where people are born, live, learn, work, play, worship, and age.”
Codes can be assigned based on self-reported data or information recorded by a member of the care team. When included in reporting, they can aid in developing risk scores for patient populations.
However, CMS reported in 2021 that Z codes were reported for only 1.6 percent of Medicare FFS beneficiaries in 2019. Just 928,000 of the 58 million Medicare beneficiaries had their SDoH factors recorded.
While we don’t have an accurate count of how many Americans are challenged with social needs, we know that approximately 37.2 million live in poverty. Waiting to treat those with social needs until they develop serious illnesses is not an acceptable solution to health equity.
2. Include geographically based SDoH data in reports
When the clinical data that identify an individual patient’s specific social needs are not available, a patient’s geographically based social determinants can inform the provider of likely needs to address. This data is available from databases that identify social factors at the census tract level, which are significantly more accurate than zip code level statistics. Census tracts are roughly equivalent to a neighborhood and typically include 2,500 to 8,000 residents.
A geographic analysis tool can leverage each patient’s street address to identify social factors within a very specific neighborhood. And analysis might include the following social factors:
- Safety
- Social connection
- Race/Ethnicity
- Migration
- Incarceration
- Military deployment
- Education
- Employment
- Finances
- Nutrition
- Housing
- Access to health services
The key to transforming these statistics into actionable insights is to identify those factors that present significant risks to each specific patient. For example, after reviewing the SDoH factors, the reports might isolate and identify housing insecurity and food insecurity as factors that have a high probability of impacting this specific patient. This, in turn, can prompt a discussion between the provider and the patient and, in many cases, result in referrals to local resources that can provide additional assistance.
