Summary of The U.S. Playbook to Address Social Determinants of Health
Building health and well-being within communities
What is The U.S. Playbook to Address Social Determinants of Health?
On November 16, 2023, the White House released “The U.S. Playbook to Address Social Determinants of Health” (The Playbook).1 The Playbook (a) contains background information on the links between social determinants of health (SDOH) and health outcomes, and (b) lays out an initial scaffolding for actions federal agencies are taking to break down institutional silos and support organizations that address individual health-related social needs (HRSNs) in order to equitably build health and well-being within communities. The Playbook is not intended to be final or comprehensive, but is rather an initial set of strategies that organizations in both the public and private sector can build upon as they implement programs to address HRSNs.2
This paper provides a brief summary of the pillars contained in The Playbook and discusses implications for various stakeholders across the healthcare industry.
Summary of The Playbook
The Playbook describes three pillars for addressing HRSNs and highlights examples of actions being taken by the U.S. government (Figure 1).
Figure 1: Pillars for individual and community-centered interventions3
Glossary of Terms
Blending “involves mixing funds together to finance a single activity without maintaining program-specific identities.”4
Braiding “involves lacing funds from multiple sources, each funding unique activities, together to support a common goal while maintaining the specific program identity of each individual funding source.”5
Community-based organizations (CBOs) are “public or private not-for-profit resource hubs that provide specific services to the community or targeted population within the community. CBOs include but are not limited to aging and disability networks, community health centers, childcare providers, home visiting programs, state domestic violence coalitions and local domestic violence shelters and programs, adult protective services programs, homeless service providers, and food banks that work to address the health and social needs of populations.”6
HRSNs (health-related social needs) refer to the immediate social needs that affect health outcomes for individuals directly and include challenges such as income instability, housing instability, and household food insecurity.7
SDOH (social determinants of health) are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.8
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Implications of The Playbook on the healthcare sector
The framework and solutions outlined in The Playbook have wide-reaching implications within the healthcare sector and offer opportunities for stakeholders, including health plans, hospital systems, community clinics, and other provider groups managing population health, to leverage existing government approaches or adapt the framework to fit their specific needs.
Pillar 1: Expand data gathering and sharing
While SDOH and HRSNs are known to contribute to health disparities, the ability to address them effectively is hindered by a significant challenge—the scarcity of comprehensive and reliable data sources.,9,10 Pillar 1 of The Playbook outlines approaches to advance data use, capture, and exchange in an effort to bridge existing data gaps, to encourage research to better understand drivers of health disparities, and to inform future policy decisions.
Some key themes in Pillar 1 of The Playbook are:
- Needing to collect and share data in a standardized format to facilitate widespread integration into care records to ensure social needs are addressed
- Maintaining privacy throughout data capture and sharing as individual HRSNs data can be particularly sensitive
- Partnering with both public and private organizations to invest in and expand data collection initiatives
- Improving data gathering and sharing for Medicaid and Children’s Health Insurance Program (CHIP) enrollees to develop policies that are relevant to addressing the needs of these populations
- Highlighting health disparities using available data while continuing to invest in enhanced data collection
Key stakeholders that may be directly affected by Pillar 1 are:
- Health plans, which may need to comply with potential future policies on standardized data collection and sharing.
- Providers, who may have newly available patient-level HRSNs data or may be required to report on HRSNs information, which could inform how they deliver care.
- Organizations managing population health, whose payment structure may be impacted as a result of emerging research using the data collected.
While data sources containing information on SDOH and HRSNs already exist, expanded data collection that links SDOH and HRSNs information to healthcare data on an individual level will improve the healthcare sector’s understanding of the relationship between these characteristics and health outcomes.
In the absence of linked data at an individual level, tools such as the Milliman Qualified Entity (QE) Reporting Dashboard can be used to help identify and understand the relationship between SDOH and health system performance at a population level using sufficiently small levels of geographic granularity.
Pillar 2: Support flexible funding for social needs
Funding to support communities can come from many sources including federal, state, local, tribal, territorial, and philanthropic sources. Traditionally, these funding streams have been siloed between social support and healthcare services, with complex rules often limiting the ability to braid or blend these funds together.
External funding is essential for nonprofit community-based organizations (CBOs) that are often working with limited resources and capacity to deliver critical social services. Through Centers for Medicare and Medicaid Services (CMS) pilots, including state-initiated 1115 demonstrations, Center for Medicare and Medicaid Innovation (CMMI) models, and other programs, the federal government is focused on increased and flexible funding opportunities to address HRSNs. Some principles underlying these programs include:
- Allowing funding to support appropriate payments to CBOs and other organizations providing social services that address HRSNs
- Making appropriate payments to providers for identifying and facilitating access to community-based services to address HRSNs by paying for clinical screening for SDOH, as included in the Medicare calendar-year 2024 Physician Fee Schedule11
- Improving accessibility to various grants
- Improving coordination between health and social service programs, including the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and the U.S. Digital Service (USDS)
- Adopting innovative payment elements, including up-front payments, social risk adjustment, benchmark adjustments, and payment incentives for reducing disparities and screening for and addressing social needs
Health plans and providers should take note of these programs and consider participation in them as applicable, as well as consider extending these principles to their commercial contracts.
Incentivizing data collection of SDOH and HRSNs and ultimately addressing needs in communities through innovative payment models and targeted funding require careful thought and strategy that can be aided by actuarial expertise. Actuaries can provide a financial ecosystem viewpoint to these transactions, uncovering both intended and unintended incentives for various stakeholders. In addition, analysis is required to ensure payments are appropriate and to capture social and health risk factors for the underlying population.
Pillar 3: Support backbone organizations
While there has been a recent increase in attention on the association between SDOH or HRSNs and health outcomes, backbone organizations, or “Community Care Hubs“ as they are often referred to, have been providing social services for years and have built trusted networks within communities. Bridge building between these backbone organizations and health plans and providers is still in its infancy.
According to The Playbook, a backbone organization is an organization that plays the role of coordinator in a cross-sector collaborative and typically manages communication between partners and the administrative burden, including contracting with healthcare organizations and managing information systems, finances, and payment.
The Playbook highlights the critical role of backbone organizations and the challenges they face, including funding, capacity, and technical capabilities. The U.S. government currently supports or has plans to support backbone organizations through providing technical support, training, and capacity building via multiple channels, including the National Institutes of Health (NIH), the Center for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the U.S. Department of Agriculture, and the U.S. Department of Housing and Urban Development (HUD). The Playbook notes that the federal government plans to invest in building more backbone organizations.
Some key themes from Pillar 3 include:
- Developing place-based networks to deliver technical assistance and capacity-building resources to organizations.
- Researching the relationship between SDOH and health outcomes to inform backbone organization work.
- Disseminating information to organizations on research findings and available resources for training and support.
- Funding “one-stop shop” approaches to address SDOH. These approaches should leverage data and social service networks to screen and refer individuals for SDOH or HRSNs.
There are several ways healthcare partners can support backbone organizations directly and indirectly to build strong, effective systems to address HRSNs.
Prior to designing a program to address HRSNs, it is important to understand the existing SDOH landscape. Providers or plans may be able to partner with a local backbone organization or a coalition of CBOs partnering to provide social services. For example, there are currently 58 organizations across 32 states participating in the Administration for Community Living (ACL) and CDC Community Care Hub National Learning Community.12
As previously mentioned, there are a few CMMI models that include direct mechanisms for providers to work with backbone organizations. For example, the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model,13 a state-wide, all-payer total cost of care payment model, requires participating states to develop a cross-sector model governance structure and provides funding to support strengthening connections between healthcare and community organizations. Other examples include Making Care Primary14 and Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH).15,16,17
Most critically, there are wide differences in how CBOs and health systems operate. For example, CBOs typically generate revenue through grants and other philanthropic dollars rather than billing for individual services like healthcare providers do. Payers and providers need to consider the current capacity, technical capabilities, and most appropriate payment model when contracting with backbone organizations to ensure they can remain financially viable and effectively deliver care when receiving referrals from health partners.
Extending Playbook scaffolding: Looking to the future
As described in The Playbook, the federal government has outlined several approaches, primarily focused on the Medicaid and Medicare programs, for advancing SDOH and HRSNs data collection and allocating funding to and supporting organizations engaged in addressing SDOH and HRSNs. However, addressing SDOH requires a cross-sector approach. As mentioned in the introduction, The Playbook is not intended to be a comprehensive blueprint, but rather scaffolding that organizations across the health system can build upon.
The pillars in The Playbook are not mutually exclusive and may be implemented in tandem. For example, flexible funding to providers and community partners is necessary to support building new data infrastructure and capacity to deliver interventions, but robust data collection and sharing can be necessary to inform initial payment strategies as well as to ensure successful referrals and communication between the health system and CBOs or other social service agencies. Close coordination and collaboration across sectors will be essential to make these complex changes and achieve the ultimate outcome of better and more equitable health and well-being within communities.
While The Playbook includes scaffolding for where to begin, as well as current structural actions federal agencies are taking to support equitable health outcomes, the landscape continues to evolve in ways that could have implications for a variety of stakeholders across the healthcare industry. While federal policy can be a catalyst for change, sustained change and innovation will require active participation from stakeholders across the entire care delivery and coordination system. Private and local programs have the opportunity to innovate and generate research to drive the adoption of evidence-based approaches. Those operating in the healthcare space may consider developing programming to support these pillars in their organizations, including analyses to assess potential impacts.
1Domestic Policy Council Office of Science and Technology Policy (November 2023). The U.S. Playbook to Address Social Determinants of Health. Retrieved December 4, 2023, from https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-3.pdf.
6Administration for Strategic Preparedness and Response. Promising Practices for Reaching At-Risk Individuals for COVID-19 Vaccination and Information. U.S. Department of Health and Human Services. Retrieved December 4, 2023, from https://aspr.hhs.gov/at-risk/Pages/engaging_CBO.aspx#:~:text=Community%2DBased%20Organizations%20(CBOs),targeted%20population%20within%20the%20community.
7World Health Organization. Social Determinants of Health. Retrieved December 4, 2023, from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1.
9Healthy People 2030. Social Determinants of Health. U.S. Department of Health and Human Services. Retrieved December 4, 2023, from https://health.gov/healthypeople/priority-areas/social-determinants-health.
10The Playbook, op cit., pages 9-12, 19.
11CMS (November 2, 2023). Calendar-Year (CY) 2024 Medicare Physician Fee Schedule Final Rule – Medicare Shared Savings Program Fact Sheet. Retrieved December 4, 2023, from https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program.
12ACL (November 4, 2022). ACL Announces Selected Participants of the Community Care Hub National Learning Community. Retrieved December 4, 2023, from https://acl.gov/news-and-events/announcements/acl-announces-selected-participants-community-care-hub-national.
13CMS. States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. Retrieved December 4, 2023, from https://www.cms.gov/priorities/innovation/innovation-models/ahead.
14CMS. Making Care Primary (MCP) Model. Retrieved December 4, 2023, from https://www.cms.gov/priorities/innovation/innovation-models/making-care-primary.
15CMS. ACO REACH. Retrieved December 4, 2023, from https://www.cms.gov/priorities/innovation/innovation-models/aco-reach.
16Bilz, M., Davenport, S., Jensen, B. et al. (December 2022). ACO REACH: Leveraging Data to Reach the Underserved and Address Disparities. Milliman White Paper. Retrieved December 4, 2023, from https://www.milliman.com/en/insight/aco-reach-leveraging-data-to-reach-the-underserved.
17Bryon, D., Champagne, N., Jensen, B., & Norris, C. (March 2022). ACO REACH: Direct Contracting 2.0. Milliman White Paper. Retrieved December 4, 2023, from https://www.milliman.com/en/insight/aco-reach-cmmi-latest-innovation.