Humana, National Quality Forum Execs: Future Payment Models Must Consider Social Determinants of Health

Physician leaders from Louisville, Kentucky-based Humana Inc. (NYSE: HUM) and the National Quality Forum have published a joint article in the New England Journal of Medicine examining the role social, behavioral and environmental factors play in overall health — and why those aspects should be incorporated into future payment models. 

Published Wednesday, the piece is yet another reminder of how health care is embracing and being changed by social determinants of health.

In their article, Humana CMO Dr. William Shrank and National Quality Forum CEO Dr. Shantanu Agrawal argue for including social factors, in addition to clinical factors, when constructing population-based payment models.


Broadly, the authors believe increased consideration of social risk factors in payment models would create provider incentives for addressing health-related social needs, in turn improving outcomes. Those needs include access to health food, safe environments and social support, among others.

Humana has been one of the payers — and providers — at the forefront of the social determinants conversation.

In 2014, for example, Humana launched its “Bold Goal” strategy, which aimed to tackle some of the problems related to social determinants of health. Since then, Humana’s legacy at home division and Kindred at Home operations have focused on how they can improve the overall health of their patients by addressing social and environmental factors.


“Some evidence shows that performance-based reimbursement programs penalize or reduce payments to providers who care for socially disadvantaged people, which suggests that existing risk-adjustment methods don’t sufficiently address social context,” the New England Journal of Medicine article read.

Explicitly accounting for those social characteristics would “level the playing field” by providing clinicians with the right resources to care for more vulnerable patient populations.

“Growing evidence indicates that socially disadvantaged people have comparatively worse health outcomes, suggesting that clinical and social risk are related,” Dr. Agrawal, who also serves as president of the National Quality Forum, said in a statement. “To improve the health outcomes of all people, including the disadvantaged, we must consider this growing body of evidence as part of a comprehensive, 21st century approach to risk adjustment.”

The topics of social determinants of health and improving outcomes is particularly relevant at this point in time. The COVID-19 crisis, Shrank and Agrawal point out, can exacerbate these social, behavioral and environmental gaps in health care.

Those with reduced access to adequate health care, for instance, are more likely to have underlying conditions such as hypertension and diabetes. Such underlying conditions make bouts with the coronavirus more dangerous.

On its end, Humana waived customer cost-sharing and co-pays related to coronavirus treatment.

“Our proactive outreach to our COVID-19-positive and highest risk members has uncovered high rates of social isolation and considerable barriers to accessing healthy food, which put them at higher risk for bad outcomes,” Shrank said in a statement. “Given the associations between social risk and clinical risk, it stands to reason that risk adjustment for payment models should incorporate the breadth of patient characteristics that predict the need for health care services.”

The Centers for Medicare & Medicaid Services (CMS) has aimed to address social determinants of health in recent years, in part by expanding Medicare Advantage (MA) supplemental benefits.

The Special Supplemental Benefits for the Chronically Ill (SSBCI) program, for instance, allows plans to cover services like non-medical transportation, meal support and home modification, among others.

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