More Thinking and Insights

3 Questions for Healthcare Leaders

May 18, 2021  |  Article


Yogin Shroff, Senior Partner and Chief Operating Officer

These are the questions healthcare leaders should consider on the road to improving the social determinants.

Improving the social determinants requires concerted effort and dedication. From planning and strategizing to collaborating and integrating, one may reasonably ask, "Am I working on the right things?" The questions that follow provide a useful check.

1. Who is accountable for social determinants and population health in my organization?

Organizations that create specific roles, functions and structures to plan and execute social determinant strategy tend to outperform their contemporaries. Consider the example of Geisinger Health in Pennsylvania. Geisinger implemented its Fresh Food Farmacy to empower front-line clinicians to address food insecurity by encouraging providers to prescribe food as they would medication. This, combined with timely follow-up with nutritional coaching and education, directly addressed some systemic issues among the health plan's high-risk chronic members. Perhaps most notably, the program moved the needle with respect to avoidable hospitalizations.

"Our Fresh Food Farmacy is just one example of our fundamentally different approach to improving health," says Karen Murphy, RN, PhD, Geisinger EVP and Chief Innovation Officer.1 Geisinger's example is a master class in innovative SDoH thinking and execution, and highlights the indispensability of having the right people in the right roles.

2. Is my organization equipped to create and apply member-level predictive analytics?

Within the healthcare sector, organizations that adopt predictive technology — restated, those that 'go on the offensive' against social barriers — excel at population health management. Just how effective are healthcare organizations at performing predictive analytics and tying analytics to action? Too often, the traditional scope of these programs misses the mark with respect to improving outcomes among vulnerable individuals. See the traditional pillars of CMS Stars:

The primary aim of the physical health measure set is to ensure that members complete necessary screenings and exams. One should ask, "Does my organization know the inherent social barriers that may prevent members from visiting their PCP in the first place?"

Similarly, CAHPS scores seek to maximize member satisfaction. One should ask, "How do we define satisfaction, and what does that mean for our most disadvantaged population?" Finally, the Pharmacy clinical measure set prioritizes medication adherence as its primary aim. "Does my organization understand the way transportation and access limit members' ability to adhere to their prescriptions?"

The preceding are only a few examples in which analytics provide texture to strategy, and meaningfully inform execution. This translates directly to better outcomes for members, and better fiscal performance for the health plan.

3. How does my organization measure health outcomes from population health and SDoH interventions?

In far too many cases, institutions are limited in the way they monitor SDoH program progress. The predictive data capabilities described previously are ineffective where program controls are nonexistent. For a program to be effective, its leaders must be able to answer questions like, "How many members signed up for this intervention?” and “What is the hospital utilization trend for a given member over a given date span?” Any difficulty answering these is symptomatic of a need for data-driven objectivity.

Program oversight enables visibility down to the member level, while surfacing larger trends like member cost of care and return on investment.

Where do we go from here?

Organizations must be intentional about utilizing enabling technologies, data analytics and program oversight to optimize health plan performance and improve member health outcomes.


1 Geisinger (2019, July 11) Geisinger brings Fresh Food Farmacy to Scranton. Retrieved from

Ready to learn more? We'd love to hear from you.