Addressing Health-Related Social Needs

Physicians have long experienced the impact of social and environmental conditions, known as social drivers of health (SDOH), on patient health, care outcomes, costs, physician burden and the physician-patient relationship. Indeed, in part one of The Physicians Foundation’s 2021 Survey of America’s Physicians, nearly all physicians indicated their patients’ health outcomes are affected by at least one SDOH.

While 9 in 10 physicians want to address patients’ social drivers of health, 6 in 10 lack the time and ability to do so.

For more than a decade – and long before most stakeholders in the health care system – The Physicians Foundation has been on the vanguard of recognizing and acting on these challenges.

The 2022 Survey of America’s Physicians also found that eight in 10 physicians believe that the United States cannot improve health outcomes or reduce health care costs without addressing SDOH. This shows that physicians need strategies and structures in place to support their efforts to address patients’ SDOH.

To bring physicians the support they need, the Foundation first collaborated with Health Leads to develop and implement the first-ever system to help enable physicians to screen their patients and automatically connect or refer them with the basic resources they need to be healthy.

The Foundation also supported the publication of a book by Richard (Buz) Cooper, MD, Poverty and the Myths of Health Care Reform. The book argued that poverty, rather than overutilization, waste and physician inefficiency, are the drivers of runaway health care costs.

Today, through the Foundation’s collaboration with The Health Initiative, the North Carolina Medical Society, the Texas Medical Association and the Medical Society of the State of New York are addressing the impact of poverty on health outcomes and costs by focusing on payment and delivery system reform, and physician burnout.

Most recently, the Foundation released Improving America’s Health Care System: Recognize the Realities of Patients’ Lives and Invest in Addressing Social Drivers of Health, which outlines specific, practical recommendations that are needed to address SDOH that impact physicians and patients across the country.

Consistent with these recommendations, the Foundation submitted to the Centers for Medicare and Medicaid Services (CMS) the first-ever SDOH measure set to be included in federal payment programs:

  • % of beneficiaries ≥18 years screened for food insecurity, housing instability, transportation problems, utility help needs, and interpersonal safety; and
  • % of beneficiaries ≥18 years who screen positive for food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety.

CMS has included these SDOH measures in its “measures under consideration” list. Importantly, these measures (stratified by race/ethnicity) have been well-tested in over 600 clinical sites across the country through the CMS Innovation Center’s Accountable Health Communities model. These measures reflect the Foundation’s commitment to ensuring that payment models measure what actually matters to physicians and their patients.

Explore Our Work to Address Social Factors and Improve Health Outcomes