Social Determinants of Health: Clinical Metrics in Disguise

Social determinants of health care have always been a part of good care.  Having a good mom look after us as children was just as important as some of the medication we reluctantly swallowed in order to get better.  Yet when considering the cost or contribution to a good outcome, the gentle hand of a dedicated mother is rarely considered. 

Our society is finally waking up to the fact that social factors do have a direct impact on health outcomes and health care spending.  The elementary questions are clear:  What good is a prescription if the patient cannot afford the cost?   Is an available appointment any use to a person who has no transportation?  Is the insulin for a diabetic of any value if her refrigerator does not work or does not exist?   Is it more cost effective to build a ramp at home or move the elderly disabled patient into a nursing home facility?  The questions are endless and individualized, yet each one affects patient outcomes and the cost of their health care.

Our independent streak usually rises up at this point in the conversation by asking if we have any measure of personal responsibility.  While this question is legitimate, it begs for an answer to this additional question:  What about those individuals who do not have capacity for personal responsibility?  While we might justly complain about the elderly patient receiving housekeeping services in a home where three generations live, on the other hand, we cannot ignore the elderly person living alone who needs some help to keep them at home without any close family.   The alternative for the elderly patient is often being summarily confined to a nursing facility.  When limited care is needed, keeping that person at home is generally cheaper than a facility.  Additionally, home care is more accessible for friends, church, and remote family.[i]

Open Mind’s Monica Oss has raised thoughtful attention to “The Thinning Line Between Health Care and Social Services” in a recent publication.[ii]  She describes the slow shift in the necessary policies that now are beginning to support the value of making social determinants part of the health care process.  In fact, CMS is putting out some of the details of the shift in the 2020 Medicare Advantage Rate Announcement and Final Call Letter.  A primary goal of CMS is to keep the elderly and disabled in the community.  Some of the Medicare Advantage services could include transportation to health care appointments, meal delivery, adult day care services, programs to improve memory, and even shampooing the asthmatic’s carpet along with home modifications focused on keeping folks at home and functioning.[iii]

This is a significant policy shift for CMS and, in fact, a new focus on the time-tested concept of “whole person” care.  It is only sensible that this expanded-care concept extend to all Medicare patients.  An important element at the middle of this remarkable shift will be a data analytic system that will track, measure, and account for the process and progress of the beneficiaries.   Salient Healthcare has already produced and implemented such a system on the Medicaid side of the equation incorporating claims data, useful elements of the medical record, and the social determinants available in the Medicaid system, all of which are rationalized at the beneficiary level.  Social determinants then become legitimate clinical metrics. As social determinants become an integral part of health care, it is reasonable to consider them a clinical metric deserving of measuring and tracking.  If the triple aim is still our ultimate goal, any program must be measured against the established principles of better care, lower cost, and better patient satisfaction.


[i]   https://www.elderlawanswers.com/home-care-may-not-be-cheaper-than-assisted-living-or-a-nursing-home-6056

[ii]  https://www.openminds.com/market-intelligence/executive-briefings/expanding-coverage-for-a-whole-person-model-of-care/

[iii] https://www.cms.gov/newsroom/fact-sheets/2020-medicare-advantage-and-part-d-rate-announcement-and-final-call-letter-fact-sheet

Craigan Gray

About the Author


Craigan Gray, MD, MBA, JD

Dr. Craigan Gray, Salient Healthcare’s Chief Medical Officer, brings rich experience from private practice, hospital leadership, and governmental health-benefit programs. Prior to joining Salient, Dr. Gray was director of North Carolina’s $12 billion Medicaid program. His time as VPMA at Bon Secours Our Lady of Bellefonte Hospital in Kentucky was distinguished by moving the facility into the top-quality performance tier for Health Grades and CMS health quality indicators. Dr. Gray is a Stanford University trained Obstetrician/Gynecologist. In addition to an MD degree, Dr. Gray holds an MBA degree and a JD degree. He is a Certified Physician Executive and is published in various medical journals.

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