More Thinking and Insights

SDoH Impact on HEDIS

April 03, 2021  |  Guidance


Yogin Shroff, Senior Partner and Chief Operating Officer

Social determinants largely dictate an individual's ability to complete critical screenings and necessary healthcare activities, vital to the success of an organization's HEDIS and Stars ratings.

HEDIS and the Social Determinants of Health

Even as member experience continues to grow in importance, health plans and systems must tactfully ensure its members are fulfilling their necessary medical needs, both for the member's well-being but also to keep potential long-term costs to a minimum. However, it requires unrelenting focus around mitigating social determinants of health risk factors. Simply stated, a member's ability to complete critical health screenings and exams is dependent upon overcoming their social barriers. Without carefully addressing the root causes of illnesses, health conditions tend to worsen. Subsequently, Star ratings can suffer, causing a ripple effect both financially and in membership enrollment. Therefore, healthcare organization support in mitigating a member's social barriers, is critical.

Healthcare Access

Healthcare access happens to be one the most critical risk factors facing the underserved population today. Three of the most significant measure sets paramount in adequate access to care are annual wellness visits, cancer prevention screenings, and emergency department utilization. Regular visits with providers are vital to both meet basic medical needs and identify potentially negative health outcomes before they become more serious. Furthermore, appropriate access to care prevents abnormal use of ambulatory and ER services, keeping overall healthcare costs down. There are far too many instances in the healthcare sector where underserved members are utilizing emergency departments for routine medical needs simply due to limited access to care.

To add more depth to this discussion, the table below depicts the relationship between HEDIS measures and Social Determinants of Health.

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