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class="inline-block h-[16px] border-l-2 border-gray-400 mt-1 mx-1 relative top-[2px]"></div>Issue <span class="font-bold">Spec No. 13</span></span><div class="h-[16px] border-l-2 border-gray-400 mt-1 mx-1 "></div><div class="text-gray-500">Pages: e2-e7</div></div><h1 class="text-[26px] font-medium leading-8">Understanding the Financial Return to Investments in the Social Determinants of Health</h1><div class="py-3 text-gray-600 md:flex flex-col md:justify-between"><div class="flex flex-col xs:flex-row"><p class="mr-1 self-start">Author(s):</p><div class="flex flex-col xs:flex-row mb-3 md:mb-0"><div class="flex flex-wrap"><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/dennis-p-scanlon-phd">Dennis P. Scanlon, PhD</a><span class="mx-1">,</span></span><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/mark-sciegaj-phd">Mark Sciegaj, PhD</a></span></div></div></div><div class="max-w-full"><div class="flex flex-wrap sm:flex-nowrap items-center w-fit "></div><div class="w-full flex flex-col sm:flex-row justify-between mt-2"><div class="block md:hidden "><div class="mt-2 flex items-center max-w-fit"><button title="Understanding the Financial Return to Investments in the Social Determinants of Health" aria-label="facebook" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#3b5998"></circle><path d="M34.1,47V33.3h4.6l0.7-5.3h-5.3v-3.4c0-1.5,0.4-2.6,2.6-2.6l2.8,0v-4.8c-0.5-0.1-2.2-0.2-4.1-0.2 c-4.1,0-6.9,2.5-6.9,7V28H24v5.3h4.6V47H34.1z" fill="white"></path></svg></button><button aria-label="twitter" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg fill="#DC7633" xmlns="http://www.w3.org/2000/svg" width="32" zoomAndPan="magnify" viewBox="0 0 375 374.9999" height="32" preserveAspectRatio="xMidYMid meet" version="1.0"><defs><path d="M 7.09375 7.09375 L 367.84375 7.09375 L 367.84375 367.84375 L 7.09375 367.84375 Z M 7.09375 7.09375 " fill="#000000"></path></defs><g><path d="M 187.46875 7.09375 C 87.851562 7.09375 7.09375 87.851562 7.09375 187.46875 C 7.09375 287.085938 87.851562 367.84375 187.46875 367.84375 C 287.085938 367.84375 367.84375 287.085938 367.84375 187.46875 C 367.84375 87.851562 287.085938 7.09375 187.46875 7.09375 " fill-opacity="1" fill-rule="nonzero" fill="#000000"></path></g><g transform="translate(85, 75)"> <svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" version="1.1" height="215" width="215"><path d="M18.244 2.25h3.308l-7.227 8.26 8.502 11.24H16.17l-5.214-6.817L4.99 21.75H1.68l7.73-8.835L1.254 2.25H8.08l4.713 6.231zm-1.161 17.52h1.833L7.084 4.126H5.117z" fill="#ffffff"></path></svg> </g></svg></button><button aria-label="linkedin" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#007fb1"></circle><path d="M20.4,44h5.4V26.6h-5.4V44z M23.1,18c-1.7,0-3.1,1.4-3.1,3.1c0,1.7,1.4,3.1,3.1,3.1 c1.7,0,3.1-1.4,3.1-3.1C26.2,19.4,24.8,18,23.1,18z M39.5,26.2c-2.6,0-4.4,1.4-5.1,2.8h-0.1v-2.4h-5.2V44h5.4v-8.6 c0-2.3,0.4-4.5,3.2-4.5c2.8,0,2.8,2.6,2.8,4.6V44H46v-9.5C46,29.8,45,26.2,39.5,26.2z" fill="white"></path></svg></button><button title="Understanding the Financial Return to Investments in the Social Determinants of Health" aria-label="pinterest" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#cb2128"></circle><path d="M32,16c-8.8,0-16,7.2-16,16c0,6.6,3.9,12.2,9.6,14.7c0-1.1,0-2.5,0.3-3.7 c0.3-1.3,2.1-8.7,2.1-8.7s-0.5-1-0.5-2.5c0-2.4,1.4-4.1,3.1-4.1c1.5,0,2.2,1.1,2.2,2.4c0,1.5-0.9,3.7-1.4,5.7 c-0.4,1.7,0.9,3.1,2.5,3.1c3,0,5.1-3.9,5.1-8.5c0-3.5-2.4-6.1-6.7-6.1c-4.9,0-7.9,3.6-7.9,7.7c0,1.4,0.4,2.4,1.1,3.1 c0.3,0.3,0.3,0.5,0.2,0.9c-0.1,0.3-0.3,1-0.3,1.3c-0.1,0.4-0.4,0.6-0.8,0.4c-2.2-0.9-3.3-3.4-3.3-6.1c0-4.5,3.8-10,11.4-10 c6.1,0,10.1,4.4,10.1,9.2c0,6.3-3.5,11-8.6,11c-1.7,0-3.4-0.9-3.9-2c0,0-0.9,3.7-1.1,4.4c-0.3,1.2-1,2.5-1.6,3.4 c1.4,0.4,3,0.7,4.5,0.7c8.8,0,16-7.2,16-16C48,23.2,40.8,16,32,16z" fill="white"></path></svg></button><button aria-label="email" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#7f7f7f"></circle><path d="M17,22v20h30V22H17z M41.1,25L32,32.1L22.9,25H41.1z M20,39V26.6l12,9.3l12-9.3V39H20z" fill="white"></path></svg></button><a class="print-wrap flex justify-center items-center cursor-pointer"><svg id="print" xmlns="http://www.w3.org/2000/svg" width="24" height="24" fill="currentColor" class="print bi bi-printer" viewBox="0 0 16 16"> <path d="M2.5 8a.5.5 0 1 0 0-1 .5.5 0 0 0 0 1z"></path> <path d="M5 1a2 2 0 0 0-2 2v2H2a2 2 0 0 0-2 2v3a2 2 0 0 0 2 2h1v1a2 2 0 0 0 2 2h6a2 2 0 0 0 2-2v-1h1a2 2 0 0 0 2-2V7a2 2 0 0 0-2-2h-1V3a2 2 0 0 0-2-2H5zM4 3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1v2H4V3zm1 5a2 2 0 0 0-2 2v1H2a1 1 0 0 1-1-1V7a1 1 0 0 1 1-1h12a1 1 0 0 1 1 1v3a1 1 0 0 1-1 1h-1v-1a2 2 0 0 0-2-2H5zm7 2v3a1 1 0 0 1-1 1H5a1 1 0 0 1-1-1v-3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1z"></path></svg></a></div><style> .print-wrap { width: 32px; height: 32px; background: #7F7F7F; border-radius: 100%; } .print { background: #7F7F7F; color: white; padding: 2px; border-radius: 100%; } </style></div></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><p class="py-2 mb-2 text-sm italic text-gray-600">The policy community should consider these concrete suggestions to address the challenges presented by social determinants of health.</p><div class="py-2"><div class="blockText_blockContent__TbCXh"><p class="pb-2">Although the importance of social determinants of health (SDOH) in influencing key individual and population health outcomes has been recognized by the public health and medical communities for decades,<sup class="text-inherit">1</sup> there has been increased discussion of the topic in recent years, especially in policy circles where the ongoing inequities in health outcomes and health care access and the high cost of care for various segments of the US population remain concerns.<sup class="text-inherit">2</sup> A focus on social determinants has received renewed interest at the federal, state, local, and private-sector levels as a potentially effective solution to improve these outcomes. At the federal level, the Center for Medicare and Medicaid Innovation (CMMI) has sponsored an intervention called the Accountable Health Communities (AHC) demonstration, and the HHS Office of Disease Prevention and Health Promotion has developed a Food Is Medicine initiative in response to a congressionally funded mandate.<sup class="text-inherit">3</sup> Several state Medicaid programs have filed for Section 1115 waivers to address social determinants—or health-related social needs, as they are labeled in Medicaid policy circles.<sup class="text-inherit">4</sup> Some states such as Massachusetts and Minnesota have leveraged Medicaid expansion under the Affordable Care Act (ACA) to experiment with paying health care providers and health care plans to address patient SDOH needs.<sup class="text-inherit">5</sup> Even private-sector health insurance plans and self-insured employers are considering adding benefits related to food, housing, and transportation to improve the health of individuals and covered populations, with a recent study by Velasquez et al<sup class="text-inherit">6</sup> indicating that private insurers have increased spending in this area, albeit modestly, to assist patients and clinicians with SDOH screening and needed services.</p><p class="pb-2">Despite the increased awareness of and emphasis on the role of social determinants as influential in important health outcomes, these efforts have faced at least 3 fundamental challenges. First, although there is evidence of the association of SDOH with important individual and population health outcomes, there is a dearth of evidence regarding the effectiveness of interventions that seek to improve health outcomes at scale for the population. This is what motivated, in part, the CMMI demonstration mentioned above. Second, and related, there is not a strong understanding of the return on investment (ROI) for SDOH interventions, including important factors such as which stakeholders make the investment, which stakeholders reap the benefits of the investment (including how best to monetize nonfinancial outcomes), and the time horizon for expecting to see an ROI. Third, some believe that attempts to address SDOH in the US have taken a heavy medicine-centric approach, relying on health care providers and systems to lead, rather than capitalizing on the significant expertise and experience that exist within community-based organizations (CBOs), entities that already have an established presence in communities and have a track record of providing services, albeit often doing so with insufficient funding and with little systematic coordination and integration with medical and public health service providers. As a result of these challenges, the field is crowded with lots of discussion of the topic and there has been some movement in terms of intervention, but there also is a significant lack of objective data on the best strategies to address SDOH at scale. SDOH can incorporate many things, which makes general statements about the broad term difficult to assess absent more details about what specifically is meant. In the US, the most discussed components of SDOH are housing, food and nutrition, transportation, income and financial resources, education, personal safety, and health care access.<sup class="text-inherit">7</sup> In this article, we address these challenges with the goal of providing concrete suggestions for the policy community regarding where focused attention could be beneficial.</p><p class="pb-2"><strong>Goals of Addressing the SDOH</strong></p><p class="pb-2">Some of the often-cited benefits of addressing SDOH include improved population health outcomes and life quality and the possibility of reduced health services utilization that correspondingly lowers costs.<sup class="text-inherit">8</sup> Approaches to better understanding and intervening in SDOH also have the potential to reduce the substantial health inequities that have been well-documented in the US.<sup class="text-inherit">9</sup> Because reduced health spending can limit revenue for health care systems and providers, a key question to ask is whether it is reasonable to expect health systems to make investments in SDOH when doing so could harm the financial viability of these health systems and the potential financial benefits of spending reductions might be realized by other stakeholders, such as public-sector or third-party payers (who have made no investment). Alternatively, if health care systems are not incented to make the investment, then who should do so? To help further elucidate the answers to these questions and to sharpen the policy discussion, we developed a conceptual framework to illustrate the investment, outcomes, and ROI associated with addressing SDOH, including consideration of the time horizon for when potential returns to SDOH investment might begin to accrue.</p><p class="pb-2"><strong>Conceptual Framework</strong></p><p class="pb-2">Building from a diagram used by Hussein and Collins,<sup class="text-inherit">10</sup> the <a rel="nofollow noreferrer noopener" target="_blank" href="https://cdn.sanity.io/images/0vv8moc6/ajmc/cb9e9adfc28b77f6ea757402f4b7fc0ebb6e3162-1468x1046.png"><strong>Figure</strong></a> was developed to help policy makers understand the complexities of addressing SDOH and the possible business case for the government and various partners to make SDOH investments with the goal of improving well-being and health outcomes for individuals and populations. As illustrated in the Figure, the existing scientific literature has fairly solidly established that the elements that make a person—and subsequently a population—healthy are divided among 4 basic categories: socioeconomic factors (eg, adequate housing, available transportation, economic security, personal safety), individual health behaviors (eg, diet, alcohol and tobacco consumption, exercise), health and medical care services (eg, access to doctors, drugs, medical devices and procedures), and the natural environment (eg, clean air, water, climate conditions). The literature estimates that the percentage that each of these categories contributes to the health of an individual or given population is 40% for socioeconomic factors, 30% for health behaviors, 20% for health and medical care services, and 10% for the natural environment (Figure).<sup class="text-inherit">11</sup></p><p class="pb-2">Historically in the US, the 4 basic categories of factors affecting health have been addressed through a collection of complex social and health initiatives implemented independently by various stakeholders, including federal and state governments, medicine and public health providers, CBOs, and various private and philanthropic actors. For example, housing and education systems involve federal entities such as the Department of Housing and Urban Development and the Department of Education, whereas there are also state-based entities with similar areas of focus, often relying to some degree on federal funding and guidelines. The same applies to other SDOH areas as well, such as energy, food, safety and security, transportation, etc. The 4 horizontal arrows in the Figure represent these SDOH areas. As mentioned previously, in the US, a disproportionate share of funding goes to health care systems to provide curative or restorative care rather than to these other social services.<sup class="text-inherit">12</sup></p><p class="pb-2">Rather than operating in silos, as is often the status quo and is depicted by the 4 parallel arrows in the Figure, the premise for SDOH policies and investment is that better integration or partnership between the traditional health and medical care sector and the various social service organizations responsible for SDOH would yield better outcomes more efficiently. The Figure shows this concept with the overlapping circles representing more thoughtful and planned cooperation and collaboration among medicine, public health, and other sectors such as education, housing, transportation, and food. An example of a federal policy attempt to promote such alignment is the AHC program launched by CMS in 2016. The AHC demonstration sought to show that systematic integrated approaches for addressing the SDOH needs of Medicare and Medicaid beneficiaries could both improve population health outcomes and decrease overall costs of care.<sup class="text-inherit">13</sup> The AHC model looks to hospitals and health systems to partner with other public and private stakeholders to generate synergy in focus and effort around improving access to SDOH services. The Venn diagram in the Figure represents the degree to which silos are removed and stakeholders find common ground to work together, with the hypothesis that better coordination and collaboration will result in better outcomes (eg, improved health and social outcomes, improved service coordination, lower health costs, and shared savings to invest in client needs). The expected improvement in outcomes is hypothesized to result in savings in the form of reductions in health care costs and expenditures—for example, by preventing unnecessary emergency care or hospital readmissions, thus generating a positive ROI over some reasonably defined time horizon. As the Figure illustrates, a portion of the savings resulting from reduced spending can potentially be reinvested to generate future investments in SDOH, illustrating the cyclical and iterative nature of these efforts, including the investment, health and nonhealth returns, and reinvestment that might result due to efficiencies. Stated differently, the information in the Figure hypothesizes that an ROI exists and can be demonstrated if better integration and partnership among the various existing silos and associated stakeholders can occur.</p><p class="pb-2"><strong>Current Evidence</strong></p><p class="pb-2">When considering the existing published literature, it is important to recognize that although numerous studies have reported that SDOH play an important role in influencing the onset, progression, and maintenance of disease as well as promoting well-being,<sup class="text-inherit">8,14</sup> a number of these studies come from outside the US, where far more public resources are devoted to addressing SDOH.15 For example, as Bradley and Taylor<sup class="text-inherit">12</sup> discuss, the largest percentage of financial resources for addressing health in the US has gone to health care systems and curative or restorative care and not to preventive care or social services. This becomes important when considering international comparisons because both social systems (eg, tax and housing policy) and health care systems (eg, many nations provide some form of universal health care coverage) are very different in European countries, for example, which the US is often compared with on health outcomes and expenditures.</p><p class="pb-2">Taylor et al reported in a 2016 literature summary of 39 peer-reviewed articles that less than 20% of integrated health systems that invested in social services reported concurrent cost savings with improved health outcomes, with some organizations reporting monetary losses.<sup class="text-inherit">16</sup> Authors of a 2017 report on 200 health system/community partnerships reported that only 65% realized some cost savings.<sup class="text-inherit">8</sup> When considering these findings, it is important to remember that the perspective is that of the health system and thus a lack of cost savings to a health care system does not mean there were no potential gains that accrued to other stakeholders such as government payers, etc.</p><p class="pb-2">RTI International has been evaluating the CMMI AHC initiative for several years and has made some important observations. For example, it found that the AHC program promoted the systematic use of screening tools for purposes of estimating individual patient needs in the areas of SDOH, with food-related needs being the most frequently reported by beneficiaries. It also found that providers had difficulty meeting the SDOH needs identified in screening and often did not have the expertise to know how to address these needs, suggesting a role for developing a less health system–centric approach to addressing SDOH and creating more robust partnerships with CBOs that have the knowledge and skills to address specific needs and that could scale up their existing efforts if additional funding were available to support doing so. In the CMMI evaluation, <em>bridge organization</em> is a term assigned to entities in a community that serves as a conduit to help facilitate addressing the needs of those identified through screening. The CMMI demonstration included 2 specific tracks for providing assistance with SDOH—the <em>assistance track</em> and the <em>alignment track</em>, which varied the degree of formal navigation and assistance to SDOH resources (rather than simple referral to resources) provided to demonstration participants. Results from the 2018-2021 evaluation found that those receiving more formal navigation assistance had significantly fewer emergency department visits. There were also improvements in other outcomes, but these improvements did not achieve levels of statistical significance.<sup class="text-inherit">17</sup></p><p class="pb-2">The lack of conclusive evidence that addressing SDOH improves patient and population health outcomes while reducing health care costs creates a dilemma for policy makers and other stakeholders considering investments in SDOH programs. Hence, understanding whether there is a business case for health systems to invest in addressing SDOH is critical. Similarly critical is a need to understand and evaluate more dimensions of SDOH investment and impact. For example, there is evidence needed about the time horizons for measuring ROI and understanding variations in the efficacy of various types of SDOH interventions (eg, navigation, screening, direct cash equivalent assistance, tax policy changes). Although the Figure is intended to be illustrative of the business case for SDOH partnerships among health care, public health, governmental entities, and community-based social service organizations, the reality is that the business case for this work is very complex and involves multiple stakeholders, including federal and state governments, for-profit and nonprofit health care systems, CBOs, and others. In addition, the scientific evidence base for particular interventions is not well understood, and as a result, many interventions are being designed and implemented absent such data or absent implementation with fidelity in cases where an evidence base does exist. It is because of this dearth of information that Thimm-Kaiser et al<sup class="text-inherit">9</sup> developed a heuristic framework that highlights 8 different pathways by which SDOH can lead to the exacerbation or improvement of health inequities.<br/></p><p class="pb-2"><strong>Policy Recommendations</strong></p><ul class="my-2"><li class="list-disc ml-8"><strong>Leverage the federal government’s existing playbook to address SDOH</strong>. In November 2023, the Domestic Policy Council and Office of Science and Technology Policy publicly released <em>The U.S. Playbook to Address Social Determinants of Health</em>.<sup class="text-inherit">2</sup> This 49-page document reports on the data that establish the connection between SDOH and health outcomes and also suggests 3 main action areas—called pillars—for advancing investments in SDOH: expanding data gathering and sharing, supporting flexible funding for social needs, and supporting backbone organizations. Many of the suggestions contained in this playbook are consistent with the other recommendations provided here and could easily be combined with a focus on better understanding and measuring the ROI of SDOH interventions, including an analysis of how to both incentivize investments across traditional SDOH silos, while also figuring out practical approaches to redistributing subsequent returns across various stakeholders and silos to support ongoing SDOH investments.</li><li class="list-disc ml-8"><strong>Leverage the existing and underfunded expertise and experience of CBOs.</strong> The AHC demonstration and other efforts have placed too much of a primary focus on health care providers having the responsibility to screen for and solve SDOH needs. Health care providers—and the associated systems and organizations they work for—with few exceptions (eg, federally qualified health centers) have not been trained to address SDOH needs, nor do they have a reputation in the community for doing so. In fact, many CBOs that have credible experience in meeting SDOH needs have felt threatened by a health care provider–centric approach to solving SDOH issues. The federal playbook for addressing SDOH calls for improving the ability of community organizations—also called backbone organizations—to leverage their expertise and capacity and to encourage and incentivize meaningful partnerships for collaboration with health care providers.<sup class="text-inherit">2</sup> Implementing this suggestion at scale requires acknowledging that addressing the SDOH needs of patient populations requires financial resources. For example, navigators, community health workers, translators, peer coaches, and other types of nontraditional health care provider resources can be deployed to more effectively and efficiently assist those with SDOH needs rather than relying on already short-staffed health provider organizations to do the same.</li><li class="list-disc ml-8"><strong>Connect the dots and dollars to understand the impact of nontraditional health sector policies on population health and health expenditures.</strong> The federal and state governments should do an inventory of all relevant policies and government-funded assistance programs to assess the potential externalities related to health. This might be called a “health in all policies” examination. The idea is to look closely at the possible positive and negative health and health expenditure externalities associated with expenditures and interventions in each nontraditional health-related area to understand potential opportunities and synergies. This suggestion is consistent with the recommendation of <em>The U.S. Playbook to Address Social Determinants of Health</em>,<sup class="text-inherit">2</sup> which calls for expanding data gathering and sharing across existing silos. For example, by examining the impact of homelessness on health care expenditures (eg, increased emergency department use, increased hospital readmissions), government can start to understand potential linkages that may lead to an ROI in a specific area (eg, avoidable health care expenditures resulting from reduced rates of homelessness that may materialize from investments in housing policies). This suggestion encourages a deep reflection across traditional silos where budgets and associated spending that provide assistance may have an impact on health and health-related expenditures, but that impact is not currently measured and therefore is underappreciated. The playbook’s recommendation to align federally administered programs to support SDOH information exchange is a first step in this direction.<sup class="text-inherit">2</sup></li><li class="list-disc ml-8"><strong>Invest in the development of an evidence base for SDOH interventions and measurement of the ROI for SDOH interventions. </strong>Although the National Institutes of Health, National Science Foundation, and other federal research programs provide billions of dollars for research studies, very little of this money is devoted to truly understanding the impact of SDOH interventions on the health of individuals and populations, including the societal ROI resulting from such interventions. The federal government should repurpose some of this existing research spending (or allocate new monies) to fund well-designed scientific studies that will provide valuable and guiding knowledge in these areas. These include studies that examine the efficacy of specific SDOH interventions, factors that lead to fidelity of intervention implementation when an evidence base exists, and the ROI of SDOH interventions. Studies that focus on the ROI should include recognition of the time horizon and associated lags before a return may be realized, as well as the ability to account for and measure the fact that investments in one traditional siloed sector may yield returns in another traditionally siloed sector.</li><li class="list-disc ml-8"><strong>Reevaluate and repurpose the ACA’s community health needs assessment (CHNA) requirement. </strong>This ACA provision requires nonprofit hospitals to identify and address the health needs of their communities. Nonprofit hospitals are required to conduct a CHNA every 3 years and implement strategies to address these needs. The ACA requires that hospitals make public both their CHNA and their implementation strategy. However, in a 2021 cross-section study of 500 hospitals published in <em>JAMA, </em>investigators reported that only 60% of the hospitals in the study published the necessary documentation to meet this requirement.<sup class="text-inherit">18</sup> Given the federal SDOH playbook, perhaps it is time to strongly consider repurposing this ACA requirement to address SDOH needs more directly in a community. Such a repurposing would be consistent with the other recommendations mentioned above and would ensure that SDOH is an explicit priority when understanding the health improvement needs of a community.</li><li class="list-disc ml-8"><strong>Tie value-based payment models to health and SDOH health-producing activities and interventions.</strong> Although CMS has set goals to move 100% of health care payments to value-based models by 203019 and has incorporated some incentives to address health-related social needs, fee-based transactional payments, or retrospective spending reconciliations based on fee-based transactions, remain dominant in the US. CMS and CMMI should strengthen their value-based models to think more robustly about how to screen for and measure SDOH needs and how to better incentivize investments in SDOH. A caveat is that this suggestion is made with the understanding that the evidence base for SDOH is both limited and still emerging (as per the suggestion to invest in more research to produce such evidence).</li></ul><p class="pb-2"><strong>Conclusion</strong></p><p class="pb-2">In the past decade, we have seen a growing emphasis on and experimentation with local health care and social service organizations collaborating on addressing SDOH, but there has not been a systematic effort to accumulate outcomes to create an evidence base for future efforts or investments. Addressing the SDOH would align the US with other high-income countries in recognizing that individual and population health is determined by many factors beyond the traditional health care system. Although the US spends the most on health care as a portion of gross domestic product and per capita, in comparison with other high-income nations, it spends the least on social services that would address SDOH. Our recommendations are practically feasible and would likely be met with significant bipartisan support, especially because consideration of both spending and outcomes across existing silos is not only compelling on its own but can also be considered fiscally responsible. <br/></p><p class="pb-2"><strong>Acknowledgments</strong></p><p class="pb-2">The authors would like to thank several former students and research assistants, including Bethany Shaw and Dora Hunter, for their input and assistance with prior versions of this manuscript. They also appreciate the editorial assistance of Tess Wilson.</p><p class="pb-2"></p><p class="pb-2"><strong>Author Information</strong></p><p class="pb-2">Dr Scanlon is Distinguished Professor of Health Policy and Administration at The Pennsylvania State University in University Park and the editor in chief of <em>Population Health, Equity & Outcomes</em>. 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href="/view/us-adhd-stimulant-shortage-highlights-growing-challenges-in-adult-treatment?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/b6fb5039fb065b6265bd44eb4eb365c5b2c92738-3115x2076.jpg?fit=crop&auto=format" alt="medicine pills - Kwangmoozaa - stock.adobe.com.jpeg" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 27th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/us-adhd-stimulant-shortage-highlights-growing-challenges-in-adult-treatment?utm_source=www.ajmc.com&utm_medium=relatedContent">US ADHD Stimulant Shortage Highlights Growing Challenges in Adult Treatment</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/giuliana-grossi">Giuliana Grossi</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/us-adhd-stimulant-shortage-highlights-growing-challenges-in-adult-treatment?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">While name brands like Adderall and Vyvanse may have been recently removed from the FDA Drug Shortage Database, it's unclear if it'll last; meanwhile, many generic forms of attention-deficit/hyperactivity disorder (ADHD) medication are still in short supply.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/frameworks-for-advancing-health-equity-wellness-way?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/a1728e6a06fccde8af20d2308f860344f9776b8f-800x400.jpg?fit=crop&auto=format" alt="Managed Care Cast" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 21st 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/frameworks-for-advancing-health-equity-wellness-way?utm_source=www.ajmc.com&utm_medium=relatedContent">Frameworks for Advancing Health Equity: Wellness Way</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/giuliana-grossi">Giuliana Grossi</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/frameworks-for-advancing-health-equity-wellness-way?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">The Wellness Way facility was designed to improve access to comprehensive outpatient care and address social determinants of health for a diverse patient population.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex md:hidden justify-center items-center"></div><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/new-proposal-aims-to-expand-medicaid-and-medicare-coverage-for-obesity-drugs?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/6bd0e6a5c734135abb6fa97501b6375dc31df9c2-5600x3733.jpg?fit=crop&auto=format" alt="Medicare enrollment model | image credit: Vitalii Vodolazskyi - stock.adobe.com" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 26th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/new-proposal-aims-to-expand-medicaid-and-medicare-coverage-for-obesity-drugs?utm_source=www.ajmc.com&utm_medium=relatedContent">New Proposal Aims to Expand Medicaid and Medicare Coverage for Obesity Drugs</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/kyle-munz">Kyle Munz</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/new-proposal-aims-to-expand-medicaid-and-medicare-coverage-for-obesity-drugs?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">If made official, the proposed rule would give Part D and Medicaid beneficiaries expanded coverage to antiobesity drugs starting in 2026. </div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/breaking-the-cycle-the-importance-of-early-intervention-in-hidradenitis-suppurativa?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/4d74ae04b0508977864936ec08f2aaa199758e5c-1000x563.jpg?fit=crop&auto=format" alt="Managed Care Cast" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">October 29th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/breaking-the-cycle-the-importance-of-early-intervention-in-hidradenitis-suppurativa?utm_source=www.ajmc.com&utm_medium=relatedContent">Breaking the Cycle: The Importance of Early Intervention in Hidradenitis Suppurativa</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/giuliana-grossi">Giuliana Grossi</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/breaking-the-cycle-the-importance-of-early-intervention-in-hidradenitis-suppurativa?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">Prompt care supports mental well-being, as hidradenitis suppurativa is often associated with depression and anxiety due to its physical and social challenges.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/trio-of-doctors-nominated-for-cdc-fda-surgeon-general?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/0db49c35d2b2fca45515dda034b8cb45fa017ede-1200x738.jpg?fit=crop&auto=format" alt="Governmentgraphic | Image Credit: © Egor-stock.adobe.com" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 25th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/trio-of-doctors-nominated-for-cdc-fda-surgeon-general?utm_source=www.ajmc.com&utm_medium=relatedContent">Trio of Doctors Nominated for CDC, FDA, Surgeon General</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/maggie-l-shaw">Maggie L. Shaw</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/trio-of-doctors-nominated-for-cdc-fda-surgeon-general?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">On Friday, President-elect Donald Trump announced his nominations to lead the CDC, for FDA Commissioner, and for Surgeon General.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/us-earns-another-low-grade-on-maternal-health?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/cc37a2aace163f5864db2bce48b8e24845587d91-8176x5451.jpg?fit=crop&auto=format" alt="Nurse pressing stethoscope to pregnant mother's stomach. Image credit: pressmaster – stock.adobe.com" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 25th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/us-earns-another-low-grade-on-maternal-health?utm_source=www.ajmc.com&utm_medium=relatedContent">US Earns Another Low Grade on Maternal Health</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/hayden-e-klein">Hayden E. Klein</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/us-earns-another-low-grade-on-maternal-health?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">The 2024 March of Dimes report card gave the US a D+ overall, with worse grades among Southern states.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div></div></div></div><div class="relative hidden sm:block"><div class="mt-4 overflow-hidden"><div class="flex justify-between"><div class="flex items-center clear-both pt-4 pb-2 text-3xl lg:text-2xl xl:text-3xl min-w-fit ">Related Content </div><div class="hidden lg:flex w-full flex-col justify-end items-end"><div class="hidden w-full lg:flex flex-wrap pb-2 gap-x-2 gap-y-1 justify-end items-end"></div></div></div><div class="w-full mb-2 border border-secondary"></div><div class="lg:hidden flex flex-wrap items-center"></div><div class="flex flex-wrap w-full"><div class="jsx-ad50481d5ee26850 w-full h-full"><div><div><div class="text-[8px] text-center text-gray-500 hidden">Advertisement</div><div id="div-gpt-ad-infeed-1"></div></div></div><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/us-adhd-stimulant-shortage-highlights-growing-challenges-in-adult-treatment?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/b6fb5039fb065b6265bd44eb4eb365c5b2c92738-3115x2076.jpg?fit=crop&auto=format" alt="medicine pills - Kwangmoozaa - stock.adobe.com.jpeg" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 27th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/us-adhd-stimulant-shortage-highlights-growing-challenges-in-adult-treatment?utm_source=www.ajmc.com&utm_medium=relatedContent">US ADHD Stimulant Shortage Highlights Growing Challenges in Adult Treatment</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/giuliana-grossi">Giuliana Grossi</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/us-adhd-stimulant-shortage-highlights-growing-challenges-in-adult-treatment?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">While name brands like Adderall and Vyvanse may have been recently removed from the FDA Drug Shortage Database, it's unclear if it'll last; meanwhile, many generic forms of attention-deficit/hyperactivity disorder (ADHD) medication are still in short supply.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/frameworks-for-advancing-health-equity-wellness-way?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/a1728e6a06fccde8af20d2308f860344f9776b8f-800x400.jpg?fit=crop&auto=format" alt="Managed Care Cast" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 21st 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/frameworks-for-advancing-health-equity-wellness-way?utm_source=www.ajmc.com&utm_medium=relatedContent">Frameworks for Advancing Health Equity: Wellness Way</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/giuliana-grossi">Giuliana Grossi</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/frameworks-for-advancing-health-equity-wellness-way?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">The Wellness Way facility was designed to improve access to comprehensive outpatient care and address social determinants of health for a diverse patient population.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex md:hidden justify-center items-center"></div><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/new-proposal-aims-to-expand-medicaid-and-medicare-coverage-for-obesity-drugs?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/6bd0e6a5c734135abb6fa97501b6375dc31df9c2-5600x3733.jpg?fit=crop&auto=format" alt="Medicare enrollment model | image credit: Vitalii Vodolazskyi - stock.adobe.com" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 26th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/new-proposal-aims-to-expand-medicaid-and-medicare-coverage-for-obesity-drugs?utm_source=www.ajmc.com&utm_medium=relatedContent">New Proposal Aims to Expand Medicaid and Medicare Coverage for Obesity Drugs</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/kyle-munz">Kyle Munz</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/new-proposal-aims-to-expand-medicaid-and-medicare-coverage-for-obesity-drugs?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">If made official, the proposed rule would give Part D and Medicaid beneficiaries expanded coverage to antiobesity drugs starting in 2026. </div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/breaking-the-cycle-the-importance-of-early-intervention-in-hidradenitis-suppurativa?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/4d74ae04b0508977864936ec08f2aaa199758e5c-1000x563.jpg?fit=crop&auto=format" alt="Managed Care Cast" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">October 29th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/breaking-the-cycle-the-importance-of-early-intervention-in-hidradenitis-suppurativa?utm_source=www.ajmc.com&utm_medium=relatedContent">Breaking the Cycle: The Importance of Early Intervention in Hidradenitis Suppurativa</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/giuliana-grossi">Giuliana Grossi</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/breaking-the-cycle-the-importance-of-early-intervention-in-hidradenitis-suppurativa?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">Prompt care supports mental well-being, as hidradenitis suppurativa is often associated with depression and anxiety due to its physical and social challenges.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/trio-of-doctors-nominated-for-cdc-fda-surgeon-general?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/0db49c35d2b2fca45515dda034b8cb45fa017ede-1200x738.jpg?fit=crop&auto=format" alt="Governmentgraphic | Image Credit: © Egor-stock.adobe.com" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 25th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/trio-of-doctors-nominated-for-cdc-fda-surgeon-general?utm_source=www.ajmc.com&utm_medium=relatedContent">Trio of Doctors Nominated for CDC, FDA, Surgeon General</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/maggie-l-shaw">Maggie L. Shaw</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/trio-of-doctors-nominated-for-cdc-fda-surgeon-general?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">On Friday, President-elect Donald Trump announced his nominations to lead the CDC, for FDA Commissioner, and for Surgeon General.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 "><a class="jsx-ad50481d5ee26850" href="/view/us-earns-another-low-grade-on-maternal-health?utm_source=www.ajmc.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/ajmc/cc37a2aace163f5864db2bce48b8e24845587d91-8176x5451.jpg?fit=crop&auto=format" alt="Nurse pressing stethoscope to pregnant mother's stomach. Image credit: pressmaster – stock.adobe.com" width="288" class="jsx-ad50481d5ee26850 max-h-[200px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full sm:w-[46%] md:w-[65%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 25th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/us-earns-another-low-grade-on-maternal-health?utm_source=www.ajmc.com&utm_medium=relatedContent">US Earns Another Low Grade on Maternal Health</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/hayden-e-klein">Hayden E. Klein</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/us-earns-another-low-grade-on-maternal-health?utm_source=www.ajmc.com&utm_medium=relatedContent"><div class="jsx-ad50481d5ee26850 text-sm text-gray-500 py-1">The 2024 March of Dimes report card gave the US a D+ overall, with worse grades among Southern states.</div></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div></div></div></div><div class="pb-24"></div></div><script type="application/ld+json">{"@context":"https://schema.org","@type":"NewsArticle","headline":"Understanding the Financial Return to Investments in the Social Determinants of Health","datePublished":"2024-10-30T13:00:00.000Z","dateModified":"2024-10-29T20:21:25Z","inLanguage":"en-US","image":"https://cdn.sanity.io/images/0vv8moc6/ajmc/392163653f09e104957696639c04e97b952d9fed-824x412.png?fit=crop&auto=format","mainEntityOfPage":{"@type":"WebPage","@id":"https://www.ajmc.com/view/understanding-the-financial-return-to-investments-in-the-social-determinants-of-health"},"publisher":{"@type":"Organization","name":"AJMC","logo":{"@type":"ImageObject","url":"https://www.ajmc.com/ajmc_logo_inverted.png"}},"keywords":"sdoh,return on investment","articleBody":"Although the importance of social determinants of health (SDOH) in influencing key individual and population health outcomes has been recognized by the public health and medical communities for decades,1 there has been increased discussion of the topic in recent years, especially in policy circles where the ongoing inequities in health outcomes and health care access and the high cost of care for various segments of the US population remain concerns.2 A focus on social determinants has received renewed interest at the federal, state, local, and private-sector levels as a potentially effective solution to improve these outcomes. At the federal level, the Center for Medicare and Medicaid Innovation (CMMI) has sponsored an intervention called the Accountable Health Communities (AHC) demonstration, and the HHS Office of Disease Prevention and Health Promotion has developed a Food Is Medicine initiative in response to a congressionally funded mandate.3 Several state Medicaid programs have filed for Section 1115 waivers to address social determinants—or health-related social needs, as they are labeled in Medicaid policy circles.4 Some states such as Massachusetts and Minnesota have leveraged Medicaid expansion under the Affordable Care Act (ACA) to experiment with paying health care providers and health care plans to address patient SDOH needs.5 Even private-sector health insurance plans and self-insured employers are considering adding benefits related to food, housing, and transportation to improve the health of individuals and covered populations, with a recent study by Velasquez et al6 indicating that private insurers have increased spending in this area, albeit modestly, to assist patients and clinicians with SDOH screening and needed services.\n\nDespite the increased awareness of and emphasis on the role of social determinants as influential in important health outcomes, these efforts have faced at least 3 fundamental challenges. First, although there is evidence of the association of SDOH with important individual and population health outcomes, there is a dearth of evidence regarding the effectiveness of interventions that seek to improve health outcomes at scale for the population. This is what motivated, in part, the CMMI demonstration mentioned above. Second, and related, there is not a strong understanding of the return on investment (ROI) for SDOH interventions, including important factors such as which stakeholders make the investment, which stakeholders reap the benefits of the investment (including how best to monetize nonfinancial outcomes), and the time horizon for expecting to see an ROI. Third, some believe that attempts to address SDOH in the US have taken a heavy medicine-centric approach, relying on health care providers and systems to lead, rather than capitalizing on the significant expertise and experience that exist within community-based organizations (CBOs), entities that already have an established presence in communities and have a track record of providing services, albeit often doing so with insufficient funding and with little systematic coordination and integration with medical and public health service providers. As a result of these challenges, the field is crowded with lots of discussion of the topic and there has been some movement in terms of intervention, but there also is a significant lack of objective data on the best strategies to address SDOH at scale. SDOH can incorporate many things, which makes general statements about the broad term difficult to assess absent more details about what specifically is meant. In the US, the most discussed components of SDOH are housing, food and nutrition, transportation, income and financial resources, education, personal safety, and health care access.7 In this article, we address these challenges with the goal of providing concrete suggestions for the policy community regarding where focused attention could be beneficial.\n\nGoals of Addressing the SDOH\n\nSome of the often-cited benefits of addressing SDOH include improved population health outcomes and life quality and the possibility of reduced health services utilization that correspondingly lowers costs.8 Approaches to better understanding and intervening in SDOH also have the potential to reduce the substantial health inequities that have been well-documented in the US.9 Because reduced health spending can limit revenue for health care systems and providers, a key question to ask is whether it is reasonable to expect health systems to make investments in SDOH when doing so could harm the financial viability of these health systems and the potential financial benefits of spending reductions might be realized by other stakeholders, such as public-sector or third-party payers (who have made no investment). Alternatively, if health care systems are not incented to make the investment, then who should do so? To help further elucidate the answers to these questions and to sharpen the policy discussion, we developed a conceptual framework to illustrate the investment, outcomes, and ROI associated with addressing SDOH, including consideration of the time horizon for when potential returns to SDOH investment might begin to accrue.\n\nConceptual Framework\n\nBuilding from a diagram used by Hussein and Collins,10 the Figure was developed to help policy makers understand the complexities of addressing SDOH and the possible business case for the government and various partners to make SDOH investments with the goal of improving well-being and health outcomes for individuals and populations. As illustrated in the Figure, the existing scientific literature has fairly solidly established that the elements that make a person—and subsequently a population—healthy are divided among 4 basic categories: socioeconomic factors (eg, adequate housing, available transportation, economic security, personal safety), individual health behaviors (eg, diet, alcohol and tobacco consumption, exercise), health and medical care services (eg, access to doctors, drugs, medical devices and procedures), and the natural environment (eg, clean air, water, climate conditions). The literature estimates that the percentage that each of these categories contributes to the health of an individual or given population is 40% for socioeconomic factors, 30% for health behaviors, 20% for health and medical care services, and 10% for the natural environment (Figure).11\n\nHistorically in the US, the 4 basic categories of factors affecting health have been addressed through a collection of complex social and health initiatives implemented independently by various stakeholders, including federal and state governments, medicine and public health providers, CBOs, and various private and philanthropic actors. For example, housing and education systems involve federal entities such as the Department of Housing and Urban Development and the Department of Education, whereas there are also state-based entities with similar areas of focus, often relying to some degree on federal funding and guidelines. The same applies to other SDOH areas as well, such as energy, food, safety and security, transportation, etc. The 4 horizontal arrows in the Figure represent these SDOH areas. As mentioned previously, in the US, a disproportionate share of funding goes to health care systems to provide curative or restorative care rather than to these other social services.12\n\nRather than operating in silos, as is often the status quo and is depicted by the 4 parallel arrows in the Figure, the premise for SDOH policies and investment is that better integration or partnership between the traditional health and medical care sector and the various social service organizations responsible for SDOH would yield better outcomes more efficiently. The Figure shows this concept with the overlapping circles representing more thoughtful and planned cooperation and collaboration among medicine, public health, and other sectors such as education, housing, transportation, and food. An example of a federal policy attempt to promote such alignment is the AHC program launched by CMS in 2016. The AHC demonstration sought to show that systematic integrated approaches for addressing the SDOH needs of Medicare and Medicaid beneficiaries could both improve population health outcomes and decrease overall costs of care.13 The AHC model looks to hospitals and health systems to partner with other public and private stakeholders to generate synergy in focus and effort around improving access to SDOH services. The Venn diagram in the Figure represents the degree to which silos are removed and stakeholders find common ground to work together, with the hypothesis that better coordination and collaboration will result in better outcomes (eg, improved health and social outcomes, improved service coordination, lower health costs, and shared savings to invest in client needs). The expected improvement in outcomes is hypothesized to result in savings in the form of reductions in health care costs and expenditures—for example, by preventing unnecessary emergency care or hospital readmissions, thus generating a positive ROI over some reasonably defined time horizon. As the Figure illustrates, a portion of the savings resulting from reduced spending can potentially be reinvested to generate future investments in SDOH, illustrating the cyclical and iterative nature of these efforts, including the investment, health and nonhealth returns, and reinvestment that might result due to efficiencies. Stated differently, the information in the Figure hypothesizes that an ROI exists and can be demonstrated if better integration and partnership among the various existing silos and associated stakeholders can occur.\n\nCurrent Evidence\n\nWhen considering the existing published literature, it is important to recognize that although numerous studies have reported that SDOH play an important role in influencing the onset, progression, and maintenance of disease as well as promoting well-being,8,14 a number of these studies come from outside the US, where far more public resources are devoted to addressing SDOH.15 For example, as Bradley and Taylor12 discuss, the largest percentage of financial resources for addressing health in the US has gone to health care systems and curative or restorative care and not to preventive care or social services. This becomes important when considering international comparisons because both social systems (eg, tax and housing policy) and health care systems (eg, many nations provide some form of universal health care coverage) are very different in European countries, for example, which the US is often compared with on health outcomes and expenditures.\n\nTaylor et al reported in a 2016 literature summary of 39 peer-reviewed articles that less than 20% of integrated health systems that invested in social services reported concurrent cost savings with improved health outcomes, with some organizations reporting monetary losses.16 Authors of a 2017 report on 200 health system/community partnerships reported that only 65% realized some cost savings.8 When considering these findings, it is important to remember that the perspective is that of the health system and thus a lack of cost savings to a health care system does not mean there were no potential gains that accrued to other stakeholders such as government payers, etc.\n\nRTI International has been evaluating the CMMI AHC initiative for several years and has made some important observations. For example, it found that the AHC program promoted the systematic use of screening tools for purposes of estimating individual patient needs in the areas of SDOH, with food-related needs being the most frequently reported by beneficiaries. It also found that providers had difficulty meeting the SDOH needs identified in screening and often did not have the expertise to know how to address these needs, suggesting a role for developing a less health system–centric approach to addressing SDOH and creating more robust partnerships with CBOs that have the knowledge and skills to address specific needs and that could scale up their existing efforts if additional funding were available to support doing so. In the CMMI evaluation, bridge organization is a term assigned to entities in a community that serves as a conduit to help facilitate addressing the needs of those identified through screening. The CMMI demonstration included 2 specific tracks for providing assistance with SDOH—the assistance track and the alignment track, which varied the degree of formal navigation and assistance to SDOH resources (rather than simple referral to resources) provided to demonstration participants. Results from the 2018-2021 evaluation found that those receiving more formal navigation assistance had significantly fewer emergency department visits. There were also improvements in other outcomes, but these improvements did not achieve levels of statistical significance.17\n\nThe lack of conclusive evidence that addressing SDOH improves patient and population health outcomes while reducing health care costs creates a dilemma for policy makers and other stakeholders considering investments in SDOH programs. Hence, understanding whether there is a business case for health systems to invest in addressing SDOH is critical. Similarly critical is a need to understand and evaluate more dimensions of SDOH investment and impact. For example, there is evidence needed about the time horizons for measuring ROI and understanding variations in the efficacy of various types of SDOH interventions (eg, navigation, screening, direct cash equivalent assistance, tax policy changes). Although the Figure is intended to be illustrative of the business case for SDOH partnerships among health care, public health, governmental entities, and community-based social service organizations, the reality is that the business case for this work is very complex and involves multiple stakeholders, including federal and state governments, for-profit and nonprofit health care systems, CBOs, and others. In addition, the scientific evidence base for particular interventions is not well understood, and as a result, many interventions are being designed and implemented absent such data or absent implementation with fidelity in cases where an evidence base does exist. It is because of this dearth of information that Thimm-Kaiser et al9 developed a heuristic framework that highlights 8 different pathways by which SDOH can lead to the exacerbation or improvement of health inequities.\n\n\nPolicy Recommendations\n\nLeverage the federal government’s existing playbook to address SDOH. In November 2023, the Domestic Policy Council and Office of Science and Technology Policy publicly released The U.S. Playbook to Address Social Determinants of Health.2 This 49-page document reports on the data that establish the connection between SDOH and health outcomes and also suggests 3 main action areas—called pillars—for advancing investments in SDOH: expanding data gathering and sharing, supporting flexible funding for social needs, and supporting backbone organizations. Many of the suggestions contained in this playbook are consistent with the other recommendations provided here and could easily be combined with a focus on better understanding and measuring the ROI of SDOH interventions, including an analysis of how to both incentivize investments across traditional SDOH silos, while also figuring out practical approaches to redistributing subsequent returns across various stakeholders and silos to support ongoing SDOH investments.\n\nLeverage the existing and underfunded expertise and experience of CBOs. The AHC demonstration and other efforts have placed too much of a primary focus on health care providers having the responsibility to screen for and solve SDOH needs. Health care providers—and the associated systems and organizations they work for—with few exceptions (eg, federally qualified health centers) have not been trained to address SDOH needs, nor do they have a reputation in the community for doing so. In fact, many CBOs that have credible experience in meeting SDOH needs have felt threatened by a health care provider–centric approach to solving SDOH issues. The federal playbook for addressing SDOH calls for improving the ability of community organizations—also called backbone organizations—to leverage their expertise and capacity and to encourage and incentivize meaningful partnerships for collaboration with health care providers.2 Implementing this suggestion at scale requires acknowledging that addressing the SDOH needs of patient populations requires financial resources. For example, navigators, community health workers, translators, peer coaches, and other types of nontraditional health care provider resources can be deployed to more effectively and efficiently assist those with SDOH needs rather than relying on already short-staffed health provider organizations to do the same.\n\nConnect the dots and dollars to understand the impact of nontraditional health sector policies on population health and health expenditures. The federal and state governments should do an inventory of all relevant policies and government-funded assistance programs to assess the potential externalities related to health. This might be called a “health in all policies” examination. The idea is to look closely at the possible positive and negative health and health expenditure externalities associated with expenditures and interventions in each nontraditional health-related area to understand potential opportunities and synergies. This suggestion is consistent with the recommendation of The U.S. Playbook to Address Social Determinants of Health,2 which calls for expanding data gathering and sharing across existing silos. For example, by examining the impact of homelessness on health care expenditures (eg, increased emergency department use, increased hospital readmissions), government can start to understand potential linkages that may lead to an ROI in a specific area (eg, avoidable health care expenditures resulting from reduced rates of homelessness that may materialize from investments in housing policies). This suggestion encourages a deep reflection across traditional silos where budgets and associated spending that provide assistance may have an impact on health and health-related expenditures, but that impact is not currently measured and therefore is underappreciated. The playbook’s recommendation to align federally administered programs to support SDOH information exchange is a first step in this direction.2\n\nInvest in the development of an evidence base for SDOH interventions and measurement of the ROI for SDOH interventions. Although the National Institutes of Health, National Science Foundation, and other federal research programs provide billions of dollars for research studies, very little of this money is devoted to truly understanding the impact of SDOH interventions on the health of individuals and populations, including the societal ROI resulting from such interventions. The federal government should repurpose some of this existing research spending (or allocate new monies) to fund well-designed scientific studies that will provide valuable and guiding knowledge in these areas. These include studies that examine the efficacy of specific SDOH interventions, factors that lead to fidelity of intervention implementation when an evidence base exists, and the ROI of SDOH interventions. Studies that focus on the ROI should include recognition of the time horizon and associated lags before a return may be realized, as well as the ability to account for and measure the fact that investments in one traditional siloed sector may yield returns in another traditionally siloed sector.\n\nReevaluate and repurpose the ACA’s community health needs assessment (CHNA) requirement. This ACA provision requires nonprofit hospitals to identify and address the health needs of their communities. Nonprofit hospitals are required to conduct a CHNA every 3 years and implement strategies to address these needs. The ACA requires that hospitals make public both their CHNA and their implementation strategy. However, in a 2021 cross-section study of 500 hospitals published in JAMA, investigators reported that only 60% of the hospitals in the study published the necessary documentation to meet this requirement.18 Given the federal SDOH playbook, perhaps it is time to strongly consider repurposing this ACA requirement to address SDOH needs more directly in a community. Such a repurposing would be consistent with the other recommendations mentioned above and would ensure that SDOH is an explicit priority when understanding the health improvement needs of a community.\n\nTie value-based payment models to health and SDOH health-producing activities and interventions. Although CMS has set goals to move 100% of health care payments to value-based models by 203019 and has incorporated some incentives to address health-related social needs, fee-based transactional payments, or retrospective spending reconciliations based on fee-based transactions, remain dominant in the US. CMS and CMMI should strengthen their value-based models to think more robustly about how to screen for and measure SDOH needs and how to better incentivize investments in SDOH. A caveat is that this suggestion is made with the understanding that the evidence base for SDOH is both limited and still emerging (as per the suggestion to invest in more research to produce such evidence).\n\nConclusion\n\nIn the past decade, we have seen a growing emphasis on and experimentation with local health care and social service organizations collaborating on addressing SDOH, but there has not been a systematic effort to accumulate outcomes to create an evidence base for future efforts or investments. Addressing the SDOH would align the US with other high-income countries in recognizing that individual and population health is determined by many factors beyond the traditional health care system. Although the US spends the most on health care as a portion of gross domestic product and per capita, in comparison with other high-income nations, it spends the least on social services that would address SDOH. Our recommendations are practically feasible and would likely be met with significant bipartisan support, especially because consideration of both spending and outcomes across existing silos is not only compelling on its own but can also be considered fiscally responsible. \n\n\nAcknowledgments\n\nThe authors would like to thank several former students and research assistants, including Bethany Shaw and Dora Hunter, for their input and assistance with prior versions of this manuscript. They also appreciate the editorial assistance of Tess Wilson.\n\n\n\nAuthor Information\n\nDr Scanlon is Distinguished Professor of Health Policy and Administration at The Pennsylvania State University in University Park and the editor in chief of Population Health, Equity & Outcomes. Dr Sciegaj is Professor of Health Policy and Administration at The Pennsylvania State University.\n\nREFERENCES\n\nEvans RG, Stoddart GL. Producing health, consuming health care. Soc Sci Med. 1990;31(12):1347-1363. doi:10.1016/0277-9536(90)90074-3\n\nDomestic Policy Council; Office of Science and Technology Policy. The U.S. Playbook to Address Social Determinants of Health. The White House. November 2023. Accessed October 3, 2024. https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-4.pdf\n\nFood Is Medicine: a project to unify and advance collective action. Office of Disease Prevention and Health Promotion. Accessed October 3, 2024. https://health.gov/our-work/nutrition-physical-activity/food-medicine\n\nHelwig A. Section 1115 waivers: addressing health-related social needs. RTI Health Advance. March 15, 2023. Accessed October 3, 2024. https://healthcare.rti.org/insights/section-1115-waivers-explained\n\nKlein S. Paying providers to address health-related social needs: lessons from Massachusetts and Minnesota. The Commonwealth Fund. October 2, 2024. Accessed October 3, 2024. https://www.commonwealthfund.org/publications/2024/oct/paying-providers-address-health-related-social-needs\n\nVelasquez DE, Srinivasan S, Figueroa JF. Trends in social spending by private health insurers. J Gen Intern Med. 2023;38(4):1081-1083. doi:10.1007/s11606-022-07878-7\n\nSocial determinants of health. Office of Disease Prevention and Health Promotion. Accessed October 3, 2024. https://health.gov/healthypeople/priority-areas/social-determinants-health\n\nMiller E, Nath T, Line L. Working together toward better health outcomes. Center for Health Care Strategies. July 2017. Accessed October 3, 2024. https://www.chcs.org/resource/working-together-toward-better-health-outcomes/\n\nThimm-Kaiser M, Benzekri A, Guilamo-Ramos V. Conceptualizing the mechanisms of social determinants of health: a heuristic framework to inform future directions for mitigation. Milbank Q. 2023;101(2):486-526. doi:10.1111/1468-0009.12642\n\nHussein T, Collins M. The community cure for health care. Stanford Social Innovation Review. July 21, 2016. Accessed October 3, 2024. https://doi.org/10.48558/J25J-Q457\n\nWhat impacts health: explore health topics. County Health Rankings & Roadmaps. Accessed October 3, 2024. https://www.countyhealthrankings.org/what-impacts-health/county-health-rankings-model\n\nBradley EH, Taylor LA. The American Health Paradox: Why Spending More Is Getting Us Less. PublicAffairs; 2013.\n\nAccountable Health Communities (AHC) model fact sheet. CMS. January 5, 2016. Accessed October 3, 2024. https://www.cms.gov/newsroom/fact-sheets/accountable-health-communities-ahc-model-fact-sheet\n\nButler SM. Building blocks for addressing social determinants of health. JAMA. 2017;318(19):1855-1856. doi:10.1001/jama.2017.16493\n\nRubin J, Taylor J, Krapels J, et al. Are Better Health Outcomes Related to Social Expenditure? A Cross-National Empirical Analysis of Social Expenditure and Population Health Measures. RAND Europe. 2016. Accessed October 3, 2024. https://www.rand.org/content/dam/rand/pubs/research_reports/RR1200/RR1252/RAND_RR1252.pdf\n\nTaylor LA, Tan AX, Coyle CE, et al. Leveraging the social determinants of health: what works? PLoS One. 2016;11(8):e0160217. doi:10.1371/journal.pone.0160217\n\nRTI International Accountable Health Communities (AHC) Model Evaluation: Second Evaluation Report. CMS. May 2023. Accessed October 3, 2024. https://www.cms.gov/priorities/innovation/data-and-reports/2023/ahc-second-eval-rpt\n\nLopez L III, Dhodapkar M, Gross CP. US nonprofit hospitals’ community health needs assessments and implementation strategies in the era of the Patient Protection and Affordable Care Act. JAMA Netw Open. 2021;4(8):e2122237. doi:10.1001/jamanetworkopen.2021.22237\n\nValue-based payments: is the CMS’s vision for 2030 within reach? RTI Health Advance. December 1, 2022. Accessed October 3, 2024. https://healthcare.rti.org/insights/value-based-payments-and-cms-vision-for-2030\n\n","description":"The policy community should consider these concrete suggestions to address the challenges presented by social determinants of health.","author":[{"@type":"Person","name":"Dennis P. Scanlon, PhD"},{"@type":"Person","name":"Mark Sciegaj, PhD"}]}</script></div></div><div class="flex-none w-[300px] z-[9999] relative hidden md:block"><div style="top:5rem" class="sticky custom-spacing"><div class="collapse-container " style="overflow:hidden;max-height:900px;transition:max-height .4s ease-in-out"></div></div></div></div><div id="div-gpt-ad-pixel" style="width:1px;height:1px" class=""></div><noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-NK5KQXS" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript><div id="footerOuterWrap" class=" mx-auto flex"><div class="bg-[#00598D] xl:w-[70%] w-[70%] py-12 pl-auto"><div class="xxl:w-[75%] w-[90%] ml-auto"><div><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span 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Despite recognition of their importance, challenges persist, including limited evidence on intervention effectiveness and return on investment (ROI). Current efforts often rely on healthcare systems rather than community-based organizations (CBOs) with relevant expertise. A conceptual framework suggests integrating health and social services could improve outcomes and ROI. Policy recommendations include leveraging CBOs, enhancing data sharing, and investing in research to better understand SDOH interventions and their impacts.","factCheckAuthorMapping":null,"url":{"current":"understanding-the-financial-return-to-investments-in-the-social-determinants-of-health","_type":"slug"},"taxonomyMapping":[{"_createdAt":"2020-03-30T19:18:06Z","_rev":"S0vXfcLWHTxXts4KsRp3a4","parent":null,"pixelTrackingCode":null,"_updatedAt":"2022-01-19T10:23:46Z","identifier":"publications","_type":"taxonomy","name":"Publications","_id":"b4e2c61f-7db5-4899-b213-6bb29d31cba6"},{"_updatedAt":"2020-07-30T14:47:46Z","identifier":"policy","parent":{"name":"Topic","_updatedAt":"2021-10-21T10:15:35Z","identifier":"topic","isMainTopic":true,"parent":null,"_id":"15012229-f713-4f0a-8f82-7667530bb382","_createdAt":"2020-03-31T14:24:50Z","_rev":"SpZIJtjiAn4ebHE4u6sWYc","_type":"taxonomy"},"_createdAt":"2020-05-04T23:46:13Z","_type":"taxonomy","name":"Policy","_rev":"GQ2iWOdzjKwgYpKUFVt5oL","_id":"topic_policy","pixelTrackingCode":null},{"_id":"topic_value-based-care","_updatedAt":"2022-11-29T18:34:06Z","identifier":"value-based-care","parent":{"_updatedAt":"2021-10-21T10:15:35Z","identifier":"topic","isMainTopic":true,"_createdAt":"2020-03-31T14:24:50Z","_type":"taxonomy","parent":null,"name":"Topic","_id":"15012229-f713-4f0a-8f82-7667530bb382","_rev":"SpZIJtjiAn4ebHE4u6sWYc"},"pixelTrackingCode":null,"_rev":"N3gjDAQ7Gje4d3HLJ0sWGv","_type":"taxonomy","name":"Value-Based Care","_createdAt":"2020-05-04T23:46:13Z"},{"parent":{"_createdAt":"2020-03-31T14:24:50Z","parent":null,"_type":"taxonomy","identifier":"topic","_updatedAt":"2021-10-21T10:15:35Z","isMainTopic":true,"_rev":"SpZIJtjiAn4ebHE4u6sWYc","name":"Topic","_id":"15012229-f713-4f0a-8f82-7667530bb382"},"_updatedAt":"2024-06-12T13:58:15Z","summary":[{"_key":"3b7c1e2bf551","alignment":"left","asset":{"_ref":"image-5f5a1d7609b5e2167e8398bb48c8734b1ba7aca8-800x212-jpg","_type":"reference"},"widthP":70,"disableTextWrap":false,"disableLightBox":true,"_type":"figure"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The mission of the Center on Health Equity \u0026 Access is to support improvement of health care delivery and health outcomes due to health disparities by maintaining a content platform focused on education, training, frontline perspectives, and practical application of evidence-based methodologies.","_key":"cdef2f34ef460"}],"_type":"block","style":"normal","_key":"973bcb0dcce4"}],"_rev":"N7mKycgLbGtEq6btkPHYvR","name":"Center on Health Equity \u0026 Access","pixelTrackingCode":null,"identifier":"center-on-health-equity-and-access","_createdAt":"2022-11-16T22:15:20Z","usedForRecommendations":false,"_id":"4ee49086-e720-4a65-883e-4efc24de53bb","thumbnail":{"_type":"mainImage","alt":"Logo for the Center on Health Equity \u0026 Access","asset":{"_type":"reference","_ref":"image-5f5a1d7609b5e2167e8398bb48c8734b1ba7aca8-800x212-jpg"}},"_type":"taxonomy"}],"documentGroup":null,"authorMapping":[{"_type":"author","_id":"author_070e3f43d8656e3c00d357dabb30d948","_updatedAt":"2020-07-30T14:44:18Z","url":{"current":"dennis-p-scanlon-phd","_type":"slug"},"displayName":"Dennis P. Scanlon, PhD","_createdAt":"2020-05-05T10:50:00Z","_rev":"GeM6ny2T6Y1Qp0cm9jBcgM"},{"_createdAt":"2020-05-05T10:50:00Z","_rev":"GeM6ny2T6Y1Qp0cm9jBcgM","_type":"author","_id":"author_7e235fe85bfeb411cec510999319189f","_updatedAt":"2020-07-30T14:44:18Z","url":{"current":"mark-sciegaj-phd","_type":"slug"},"displayName":"Mark Sciegaj, PhD"}],"issueSection":null,"articleType":"Publication","body":[{"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"eab43a964ce0","markDefs":[],"children":[{"text":"Although the importance of social determinants of health (SDOH) in influencing key individual and population health outcomes has been recognized by the public health and medical communities for decades,","_key":"b535b971cbe30","_type":"span","marks":[]},{"text":"1","_key":"c1c074ef9681","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" there has been increased discussion of the topic in recent years, especially in policy circles where the ongoing inequities in health outcomes and health care access and the high cost of care for various segments of the US population remain concerns.","_key":"9d62693ef191"},{"marks":["superscript"],"text":"2","_key":"7f12694d8e3a","_type":"span"},{"_type":"span","marks":[],"text":" A focus on social determinants has received renewed interest at the federal, state, local, and private-sector levels as a potentially effective solution to improve these outcomes. At the federal level, the Center for Medicare and Medicaid Innovation (CMMI) has sponsored an intervention called the Accountable Health Communities (AHC) demonstration, and the HHS Office of Disease Prevention and Health Promotion has developed a Food Is Medicine initiative in response to a congressionally funded mandate.","_key":"1ac258692840"},{"_type":"span","marks":["superscript"],"text":"3","_key":"5958d9c4a5d3"},{"_type":"span","marks":[],"text":" Several state Medicaid programs have filed for Section 1115 waivers to address social determinants—or health-related social needs, as they are labeled in Medicaid policy circles.","_key":"8117ee8a5e03"},{"_type":"span","marks":["superscript"],"text":"4","_key":"516ab3255de1"},{"marks":[],"text":" Some states such as Massachusetts and Minnesota have leveraged Medicaid expansion under the Affordable Care Act (ACA) to experiment with paying health care providers and health care plans to address patient SDOH needs.","_key":"eeefb3591131","_type":"span"},{"_type":"span","marks":["superscript"],"text":"5","_key":"0a3473a0b060"},{"_type":"span","marks":[],"text":" Even private-sector health insurance plans and self-insured employers are considering adding benefits related to food, housing, and transportation to improve the health of individuals and covered populations, with a recent study by Velasquez et al","_key":"2a88bff6d609"},{"_type":"span","marks":["superscript"],"text":"6","_key":"1609906ca250"},{"_type":"span","marks":[],"text":" indicating that private insurers have increased spending in this area, albeit modestly, to assist patients and clinicians with SDOH screening and needed services.","_key":"b4a29735731a"}],"upload_doc":null},{"_key":"507e58dc5830","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_key":"83f41d97bd4f0","_type":"span","marks":[],"text":"Despite the increased awareness of and emphasis on the role of social determinants as influential in important health outcomes, these efforts have faced at least 3 fundamental challenges. First, although there is evidence of the association of SDOH with important individual and population health outcomes, there is a dearth of evidence regarding the effectiveness of interventions that seek to improve health outcomes at scale for the population. This is what motivated, in part, the CMMI demonstration mentioned above. Second, and related, there is not a strong understanding of the return on investment (ROI) for SDOH interventions, including important factors such as which stakeholders make the investment, which stakeholders reap the benefits of the investment (including how best to monetize nonfinancial outcomes), and the time horizon for expecting to see an ROI. Third, some believe that attempts to address SDOH in the US have taken a heavy medicine-centric approach, relying on health care providers and systems to lead, rather than capitalizing on the significant expertise and experience that exist within community-based organizations (CBOs), entities that already have an established presence in communities and have a track record of providing services, albeit often doing so with insufficient funding and with little systematic coordination and integration with medical and public health service providers. As a result of these challenges, the field is crowded with lots of discussion of the topic and there has been some movement in terms of intervention, but there also is a significant lack of objective data on the best strategies to address SDOH at scale. SDOH can incorporate many things, which makes general statements about the broad term difficult to assess absent more details about what specifically is meant. In the US, the most discussed components of SDOH are housing, food and nutrition, transportation, income and financial resources, education, personal safety, and health care access."},{"_type":"span","marks":["superscript"],"text":"7","_key":"ff9cd5bbf118"},{"_type":"span","marks":[],"text":" In this article, we address these challenges with the goal of providing concrete suggestions for the policy community regarding where focused attention could be beneficial.","_key":"5917a9303706"}],"_type":"block","style":"normal"},{"_key":"b9b3f4c755cf","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Goals of Addressing the SDOH","_key":"6dd79bc7fe000"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"text":"Some of the often-cited benefits of addressing SDOH include improved population health outcomes and life quality and the possibility of reduced health services utilization that correspondingly lowers costs.","_key":"9fb585f2e1e40","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"8","_key":"6a577d8c8b6e"},{"_type":"span","marks":[],"text":" Approaches to better understanding and intervening in SDOH also have the potential to reduce the substantial health inequities that have been well-documented in the US.","_key":"5cbe1288b8ca"},{"_type":"span","marks":["superscript"],"text":"9","_key":"5cf09d18a4c5"},{"_type":"span","marks":[],"text":" Because reduced health spending can limit revenue for health care systems and providers, a key question to ask is whether it is reasonable to expect health systems to make investments in SDOH when doing so could harm the financial viability of these health systems and the potential financial benefits of spending reductions might be realized by other stakeholders, such as public-sector or third-party payers (who have made no investment). Alternatively, if health care systems are not incented to make the investment, then who should do so? To help further elucidate the answers to these questions and to sharpen the policy discussion, we developed a conceptual framework to illustrate the investment, outcomes, and ROI associated with addressing SDOH, including consideration of the time horizon for when potential returns to SDOH investment might begin to accrue.","_key":"4a7cda85b343"}],"_type":"block","style":"normal","_key":"dbfcd6529a8a","upload_doc":null,"uploadAudio":null,"medias":null},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Conceptual Framework","_key":"f54fbc9ece0c0"}],"_type":"block","style":"normal","_key":"860b606dad63","upload_doc":null,"uploadAudio":null,"medias":null},{"medias":null,"_key":"376baded56d5","markDefs":[{"_type":"link","href":"https://cdn.sanity.io/images/0vv8moc6/ajmc/cb9e9adfc28b77f6ea757402f4b7fc0ebb6e3162-1468x1046.png","_key":"1072b44a40a7","nofollow":true,"blank":true}],"children":[{"marks":[],"text":"Building from a diagram used by Hussein and Collins,","_key":"08312d9e5ba10","_type":"span"},{"_type":"span","marks":["superscript"],"text":"10","_key":"3c1764aea4ac"},{"_type":"span","marks":[],"text":" the ","_key":"3239d9cde389"},{"_type":"span","marks":["strong","1072b44a40a7"],"text":"Figure","_key":"08312d9e5ba11"},{"_type":"span","marks":[],"text":" was developed to help policy makers understand the complexities of addressing SDOH and the possible business case for the government and various partners to make SDOH investments with the goal of improving well-being and health outcomes for individuals and populations. As illustrated in the Figure, the existing scientific literature has fairly solidly established that the elements that make a person—and subsequently a population—healthy are divided among 4 basic categories: socioeconomic factors (eg, adequate housing, available transportation, economic security, personal safety), individual health behaviors (eg, diet, alcohol and tobacco consumption, exercise), health and medical care services (eg, access to doctors, drugs, medical devices and procedures), and the natural environment (eg, clean air, water, climate conditions). The literature estimates that the percentage that each of these categories contributes to the health of an individual or given population is 40% for socioeconomic factors, 30% for health behaviors, 20% for health and medical care services, and 10% for the natural environment (Figure).","_key":"08312d9e5ba12"},{"_type":"span","marks":["superscript"],"text":"11","_key":"3428cdb6022b"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null},{"_key":"0bea8dfd4bc2","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_key":"4d0b9c3f0ae40","_type":"span","marks":[],"text":"Historically in the US, the 4 basic categories of factors affecting health have been addressed through a collection of complex social and health initiatives implemented independently by various stakeholders, including federal and state governments, medicine and public health providers, CBOs, and various private and philanthropic actors. For example, housing and education systems involve federal entities such as the Department of Housing and Urban Development and the Department of Education, whereas there are also state-based entities with similar areas of focus, often relying to some degree on federal funding and guidelines. The same applies to other SDOH areas as well, such as energy, food, safety and security, transportation, etc. The 4 horizontal arrows in the Figure represent these SDOH areas. As mentioned previously, in the US, a disproportionate share of funding goes to health care systems to provide curative or restorative care rather than to these other social services."},{"_type":"span","marks":["superscript"],"text":"12","_key":"6144e6ae36f9"}],"_type":"block","style":"normal"},{"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"marks":[],"text":"Rather than operating in silos, as is often the status quo and is depicted by the 4 parallel arrows in the Figure, the premise for SDOH policies and investment is that better integration or partnership between the traditional health and medical care sector and the various social service organizations responsible for SDOH would yield better outcomes more efficiently. The Figure shows this concept with the overlapping circles representing more thoughtful and planned cooperation and collaboration among medicine, public health, and other sectors such as education, housing, transportation, and food. An example of a federal policy attempt to promote such alignment is the AHC program launched by CMS in 2016. The AHC demonstration sought to show that systematic integrated approaches for addressing the SDOH needs of Medicare and Medicaid beneficiaries could both improve population health outcomes and decrease overall costs of care.","_key":"91ef58796e460","_type":"span"},{"_type":"span","marks":["superscript"],"text":"13","_key":"5e3b05f25952"},{"marks":[],"text":" The AHC model looks to hospitals and health systems to partner with other public and private stakeholders to generate synergy in focus and effort around improving access to SDOH services. The Venn diagram in the Figure represents the degree to which silos are removed and stakeholders find common ground to work together, with the hypothesis that better coordination and collaboration will result in better outcomes (eg, improved health and social outcomes, improved service coordination, lower health costs, and shared savings to invest in client needs). The expected improvement in outcomes is hypothesized to result in savings in the form of reductions in health care costs and expenditures—for example, by preventing unnecessary emergency care or hospital readmissions, thus generating a positive ROI over some reasonably defined time horizon. As the Figure illustrates, a portion of the savings resulting from reduced spending can potentially be reinvested to generate future investments in SDOH, illustrating the cyclical and iterative nature of these efforts, including the investment, health and nonhealth returns, and reinvestment that might result due to efficiencies. Stated differently, the information in the Figure hypothesizes that an ROI exists and can be demonstrated if better integration and partnership among the various existing silos and associated stakeholders can occur.","_key":"2f5bad26ca08","_type":"span"}],"_type":"block","style":"normal","_key":"3dbb5f5e0a4a","upload_doc":null},{"upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"96a782d7e789","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Current Evidence","_key":"87fc15cf11c30"}],"_type":"block"},{"_type":"block","style":"normal","_key":"2e5223824d0c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"When considering the existing published literature, it is important to recognize that although numerous studies have reported that SDOH play an important role in influencing the onset, progression, and maintenance of disease as well as promoting well-being,","_key":"6f819a00db370"},{"_type":"span","marks":["superscript"],"text":"8,14","_key":"80f52daeae28"},{"text":" a number of these studies come from outside the US, where far more public resources are devoted to addressing SDOH.15 For example, as Bradley and Taylor","_key":"ca72150de990","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"12","_key":"fff0db0d25e4"},{"text":" discuss, the largest percentage of financial resources for addressing health in the US has gone to health care systems and curative or restorative care and not to preventive care or social services. This becomes important when considering international comparisons because both social systems (eg, tax and housing policy) and health care systems (eg, many nations provide some form of universal health care coverage) are very different in European countries, for example, which the US is often compared with on health outcomes and expenditures.","_key":"f041e3fa949b","_type":"span","marks":[]}],"upload_doc":null,"uploadAudio":null,"medias":null},{"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"70968f37428f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Taylor et al reported in a 2016 literature summary of 39 peer-reviewed articles that less than 20% of integrated health systems that invested in social services reported concurrent cost savings with improved health outcomes, with some organizations reporting monetary losses.","_key":"6a7be275e0e40"},{"_key":"a680f703173f","_type":"span","marks":["superscript"],"text":"16"},{"_type":"span","marks":[],"text":" Authors of a 2017 report on 200 health system/community partnerships reported that only 65% realized some cost savings.","_key":"8373a37b413c"},{"_key":"ddecbab8eaac","_type":"span","marks":["superscript"],"text":"8"},{"_type":"span","marks":[],"text":" When considering these findings, it is important to remember that the perspective is that of the health system and thus a lack of cost savings to a health care system does not mean there were no potential gains that accrued to other stakeholders such as government payers, etc.","_key":"1bffbe92f2f9"}],"upload_doc":null},{"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"marks":[],"text":"RTI International has been evaluating the CMMI AHC initiative for several years and has made some important observations. For example, it found that the AHC program promoted the systematic use of screening tools for purposes of estimating individual patient needs in the areas of SDOH, with food-related needs being the most frequently reported by beneficiaries. It also found that providers had difficulty meeting the SDOH needs identified in screening and often did not have the expertise to know how to address these needs, suggesting a role for developing a less health system–centric approach to addressing SDOH and creating more robust partnerships with CBOs that have the knowledge and skills to address specific needs and that could scale up their existing efforts if additional funding were available to support doing so. In the CMMI evaluation, ","_key":"ef2443864d450","_type":"span"},{"_type":"span","marks":["em"],"text":"bridge organization","_key":"ef2443864d451"},{"_type":"span","marks":[],"text":" is a term assigned to entities in a community that serves as a conduit to help facilitate addressing the needs of those identified through screening. The CMMI demonstration included 2 specific tracks for providing assistance with SDOH—the ","_key":"ef2443864d452"},{"_type":"span","marks":["em"],"text":"assistance track","_key":"ef2443864d453"},{"_type":"span","marks":[],"text":" and the ","_key":"ef2443864d454"},{"_key":"ef2443864d455","_type":"span","marks":["em"],"text":"alignment track"},{"_type":"span","marks":[],"text":", which varied the degree of formal navigation and assistance to SDOH resources (rather than simple referral to resources) provided to demonstration participants. Results from the 2018-2021 evaluation found that those receiving more formal navigation assistance had significantly fewer emergency department visits. There were also improvements in other outcomes, but these improvements did not achieve levels of statistical significance.","_key":"ef2443864d456"},{"_type":"span","marks":["superscript"],"text":"17","_key":"1865b91c0407"}],"_type":"block","style":"normal","_key":"1239bf96f613","markDefs":[]},{"_key":"4eec23e67ca9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The lack of conclusive evidence that addressing SDOH improves patient and population health outcomes while reducing health care costs creates a dilemma for policy makers and other stakeholders considering investments in SDOH programs. Hence, understanding whether there is a business case for health systems to invest in addressing SDOH is critical. Similarly critical is a need to understand and evaluate more dimensions of SDOH investment and impact. For example, there is evidence needed about the time horizons for measuring ROI and understanding variations in the efficacy of various types of SDOH interventions (eg, navigation, screening, direct cash equivalent assistance, tax policy changes). Although the Figure is intended to be illustrative of the business case for SDOH partnerships among health care, public health, governmental entities, and community-based social service organizations, the reality is that the business case for this work is very complex and involves multiple stakeholders, including federal and state governments, for-profit and nonprofit health care systems, CBOs, and others. In addition, the scientific evidence base for particular interventions is not well understood, and as a result, many interventions are being designed and implemented absent such data or absent implementation with fidelity in cases where an evidence base does exist. It is because of this dearth of information that Thimm-Kaiser et al","_key":"65b7f77894b90"},{"text":"9","_key":"e04181aba657","_type":"span","marks":["superscript"]},{"text":" developed a heuristic framework that highlights 8 different pathways by which SDOH can lead to the exacerbation or improvement of health inequities.\n","_key":"c11bafe8f0c0","_type":"span","marks":[]}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"_type":"block","style":"normal","_key":"335f7a6f8fac","markDefs":[],"children":[{"marks":["strong"],"text":"Policy Recommendations","_key":"5ac7c48f5d800","_type":"span"}],"upload_doc":null,"uploadAudio":null,"medias":null},{"medias":null,"listItem":"bullet","markDefs":[],"_type":"block","upload_doc":null,"uploadAudio":null,"_key":"d8951dc7e45a","children":[{"_type":"span","marks":["strong"],"text":"Leverage the federal government’s existing playbook to address SDOH","_key":"aa367029b26d0"},{"_type":"span","marks":[],"text":". In November 2023, the Domestic Policy Council and Office of Science and Technology Policy publicly released ","_key":"aa367029b26d1"},{"_type":"span","marks":["em"],"text":"The U.S. Playbook to Address Social Determinants of Health","_key":"aa367029b26d2"},{"_type":"span","marks":[],"text":".","_key":"aa367029b26d3"},{"_type":"span","marks":["superscript"],"text":"2","_key":"d51f053021f7"},{"text":" This 49-page document reports on the data that establish the connection between SDOH and health outcomes and also suggests 3 main action areas—called pillars—for advancing investments in SDOH: expanding data gathering and sharing, supporting flexible funding for social needs, and supporting backbone organizations. Many of the suggestions contained in this playbook are consistent with the other recommendations provided here and could easily be combined with a focus on better understanding and measuring the ROI of SDOH interventions, including an analysis of how to both incentivize investments across traditional SDOH silos, while also figuring out practical approaches to redistributing subsequent returns across various stakeholders and silos to support ongoing SDOH investments.","_key":"d56205f43fc3","_type":"span","marks":[]}],"level":1,"style":"normal"},{"children":[{"marks":["strong"],"text":"Leverage the existing and underfunded expertise and experience of CBOs.","_key":"27172ed6bd980","_type":"span"},{"_type":"span","marks":[],"text":" The AHC demonstration and other efforts have placed too much of a primary focus on health care providers having the responsibility to screen for and solve SDOH needs. Health care providers—and the associated systems and organizations they work for—with few exceptions (eg, federally qualified health centers) have not been trained to address SDOH needs, nor do they have a reputation in the community for doing so. In fact, many CBOs that have credible experience in meeting SDOH needs have felt threatened by a health care provider–centric approach to solving SDOH issues. The federal playbook for addressing SDOH calls for improving the ability of community organizations—also called backbone organizations—to leverage their expertise and capacity and to encourage and incentivize meaningful partnerships for collaboration with health care providers.","_key":"27172ed6bd981"},{"_type":"span","marks":["superscript"],"text":"2","_key":"421cb35b7818"},{"marks":[],"text":" Implementing this suggestion at scale requires acknowledging that addressing the SDOH needs of patient populations requires financial resources. For example, navigators, community health workers, translators, peer coaches, and other types of nontraditional health care provider resources can be deployed to more effectively and efficiently assist those with SDOH needs rather than relying on already short-staffed health provider organizations to do the same.","_key":"3e72681c9769","_type":"span"}],"level":1,"_type":"block","style":"normal","_key":"0581166f132e","upload_doc":null,"uploadAudio":null,"markDefs":[],"medias":null,"listItem":"bullet"},{"level":1,"style":"normal","_key":"cf964a5f614b","listItem":"bullet","children":[{"text":"Connect the dots and dollars to understand the impact of nontraditional health sector policies on population health and health expenditures.","_key":"bccf20f083c20","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" The federal and state governments should do an inventory of all relevant policies and government-funded assistance programs to assess the potential externalities related to health. This might be called a “health in all policies” examination. The idea is to look closely at the possible positive and negative health and health expenditure externalities associated with expenditures and interventions in each nontraditional health-related area to understand potential opportunities and synergies. This suggestion is consistent with the recommendation of ","_key":"bccf20f083c21"},{"_type":"span","marks":["em"],"text":"The U.S. Playbook to Address Social Determinants of Health","_key":"bccf20f083c22"},{"_type":"span","marks":[],"text":",","_key":"bccf20f083c23"},{"marks":["superscript"],"text":"2","_key":"a84df182891a","_type":"span"},{"_type":"span","marks":[],"text":" which calls for expanding data gathering and sharing across existing silos. For example, by examining the impact of homelessness on health care expenditures (eg, increased emergency department use, increased hospital readmissions), government can start to understand potential linkages that may lead to an ROI in a specific area (eg, avoidable health care expenditures resulting from reduced rates of homelessness that may materialize from investments in housing policies). This suggestion encourages a deep reflection across traditional silos where budgets and associated spending that provide assistance may have an impact on health and health-related expenditures, but that impact is not currently measured and therefore is underappreciated. The playbook’s recommendation to align federally administered programs to support SDOH information exchange is a first step in this direction.","_key":"07b43d536f4b"},{"_type":"span","marks":["superscript"],"text":"2","_key":"9db44accc2d8"}],"uploadAudio":null,"_type":"block","markDefs":[],"upload_doc":null,"medias":null},{"_type":"block","upload_doc":null,"medias":null,"children":[{"_type":"span","marks":["strong"],"text":"Invest in the development of an evidence base for SDOH interventions and measurement of the ROI for SDOH interventions. ","_key":"fb1c6fb399690"},{"_type":"span","marks":[],"text":"Although the National Institutes of Health, National Science Foundation, and other federal research programs provide billions of dollars for research studies, very little of this money is devoted to truly understanding the impact of SDOH interventions on the health of individuals and populations, including the societal ROI resulting from such interventions. The federal government should repurpose some of this existing research spending (or allocate new monies) to fund well-designed scientific studies that will provide valuable and guiding knowledge in these areas. These include studies that examine the efficacy of specific SDOH interventions, factors that lead to fidelity of intervention implementation when an evidence base exists, and the ROI of SDOH interventions. Studies that focus on the ROI should include recognition of the time horizon and associated lags before a return may be realized, as well as the ability to account for and measure the fact that investments in one traditional siloed sector may yield returns in another traditionally siloed sector.","_key":"fb1c6fb399691"}],"markDefs":[],"level":1,"style":"normal","_key":"50b3d1339630","uploadAudio":null,"listItem":"bullet"},{"style":"normal","listItem":"bullet","upload_doc":null,"uploadAudio":null,"markDefs":[],"level":1,"_key":"20374329a32f","medias":null,"children":[{"marks":["strong"],"text":"Reevaluate and repurpose the ACA’s community health needs assessment (CHNA) requirement. ","_key":"bf1893404e450","_type":"span"},{"marks":[],"text":"This ACA provision requires nonprofit hospitals to identify and address the health needs of their communities. Nonprofit hospitals are required to conduct a CHNA every 3 years and implement strategies to address these needs. The ACA requires that hospitals make public both their CHNA and their implementation strategy. However, in a 2021 cross-section study of 500 hospitals published in ","_key":"bf1893404e451","_type":"span"},{"marks":["em"],"text":"JAMA, ","_key":"bf1893404e452","_type":"span"},{"_type":"span","marks":[],"text":"investigators reported that only 60% of the hospitals in the study published the necessary documentation to meet this requirement.","_key":"bf1893404e453"},{"_type":"span","marks":["superscript"],"text":"18","_key":"a604db84eb6a"},{"_type":"span","marks":[],"text":" Given the federal SDOH playbook, perhaps it is time to strongly consider repurposing this ACA requirement to address SDOH needs more directly in a community. Such a repurposing would be consistent with the other recommendations mentioned above and would ensure that SDOH is an explicit priority when understanding the health improvement needs of a community.","_key":"497f962baf4e"}],"_type":"block"},{"listItem":"bullet","children":[{"marks":["strong"],"text":"Tie value-based payment models to health and SDOH health-producing activities and interventions.","_key":"5848c1858c7f0","_type":"span"},{"_type":"span","marks":[],"text":" Although CMS has set goals to move 100% of health care payments to value-based models by 203019 and has incorporated some incentives to address health-related social needs, fee-based transactional payments, or retrospective spending reconciliations based on fee-based transactions, remain dominant in the US. CMS and CMMI should strengthen their value-based models to think more robustly about how to screen for and measure SDOH needs and how to better incentivize investments in SDOH. A caveat is that this suggestion is made with the understanding that the evidence base for SDOH is both limited and still emerging (as per the suggestion to invest in more research to produce such evidence).","_key":"5848c1858c7f1"}],"level":1,"_key":"6967056971c3","upload_doc":null,"markDefs":[],"_type":"block","style":"normal","uploadAudio":null,"medias":null},{"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Conclusion","_key":"903b923c66880"}],"_type":"block","style":"normal","_key":"789c75c68851","upload_doc":null},{"style":"normal","_key":"65a1b19130ab","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In the past decade, we have seen a growing emphasis on and experimentation with local health care and social service organizations collaborating on addressing SDOH, but there has not been a systematic effort to accumulate outcomes to create an evidence base for future efforts or investments. Addressing the SDOH would align the US with other high-income countries in recognizing that individual and population health is determined by many factors beyond the traditional health care system. Although the US spends the most on health care as a portion of gross domestic product and per capita, in comparison with other high-income nations, it spends the least on social services that would address SDOH. Our recommendations are practically feasible and would likely be met with significant bipartisan support, especially because consideration of both spending and outcomes across existing silos is not only compelling on its own but can also be considered fiscally responsible. \n","_key":"66f0197402020"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null},{"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"72b7df975890","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Acknowledgments","_key":"289f7f672bcd0"}]},{"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"5c53121f7b17","markDefs":[],"children":[{"_key":"8968b873a4c40","_type":"span","marks":[],"text":"The authors would like to thank several former students and research assistants, including Bethany Shaw and Dora Hunter, for their input and assistance with prior versions of this manuscript. They also appreciate the editorial assistance of Tess Wilson."}]},{"_key":"296f977e69f3","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"308ccbf0e7430"}],"_type":"block","style":"normal"},{"children":[{"marks":["strong"],"text":"Author Information","_key":"6e3aa3a957480","_type":"span"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"0f89c4b57281","markDefs":[]},{"upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"marks":[],"text":"Dr Scanlon is Distinguished Professor of Health Policy and Administration at The Pennsylvania State University in University Park and the editor in chief of ","_key":"3b4f7387eb060","_type":"span"},{"text":"Population Health, Equity \u0026 Outcomes","_key":"3b4f7387eb061","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":". 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meanwhile, many generic forms of attention-deficit/hyperactivity disorder (ADHD) medication are still in short supply.","_rev":"fWx7QmWGimMXMJ6HKQ76wG","ExcludeFromPubMedXML":false,"gptTakeaways":"• The stimulant shortage reveals critical gaps in ADHD treatment, especially for adults, with rising diagnoses and limited clinical guidance complicating care.\n\n• Despite increased production quotas, DEA-imposed caps restrict supply, failing to meet rising demand for ADHD medications.\n\n• Critics argue DEA quotas are overly restrictive, hindering access for patients with ADHD and exacerbating the shortage.\n\n• Calls for DEA reform emphasize prioritizing patient needs over concerns about misuse, aiming to resolve the ongoing medication shortage.","body":[{"asset":{"_ref":"image-b6fb5039fb065b6265bd44eb4eb365c5b2c92738-3115x2076-jpg","_type":"reference"},"disableLightBox":true,"imgcaption":[{"style":"normal","_key":"3ac440db751e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Accessing ADHD treatment presents numerous challenges for many adults. | Image Credit: © Kwangmoozaa - stock.adobe.com","_key":"e4d17b2d41c6"}],"_type":"block"}],"disableTextWrap":false,"alt":"medicine pills - Kwangmoozaa - stock.adobe.com.jpeg","_key":"74129970b736","alignment":"right","_type":"figure","widthP":38},{"markDefs":[],"children":[{"text":"The ongoing shortage of stimulant medications has exposed critical gaps in the treatment of attention-deficit/hyperactivity disorder (ADHD), particularly for adults, in whom rising diagnoses, stigma, and limited clinical guidance complicate care.","_key":"2f160bf88c0b0","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"1","_key":"36257bea91f7"},{"_type":"span","marks":[],"text":" Patients face mounting barriers to care, highlighting the urgent need for improved diagnostics, evidence-based guidelines, and equitable access to medications.","_key":"2b26c972b206"}],"_type":"block","style":"normal","_key":"dfb6f597bce6"},{"markDefs":[],"children":[{"text":"","_key":"df0a9ec0f81d","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"8928a23a4707"},{"markDefs":[],"children":[{"text":"While name brands like Adderall and Vyvanse may have been recently removed from the FDA Drug Shortage Database, it's unclear if it'll last; meanwhile, many generic forms of ADHD medication are still in short supply.","_key":"79c9822935cc","_type":"span","marks":[]},{"_key":"b3f405bb57e2","_type":"span","marks":["superscript"],"text":"2,3"}],"_type":"block","style":"normal","_key":"aec75ef587c9"},{"children":[{"_type":"span","marks":["superscript"],"text":"","_key":"eeb1629ff381"}],"_type":"block","style":"normal","_key":"4c0b5fe18994","markDefs":[]},{"style":"normal","_key":"5525ba62f2f2","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2825280","_key":"be1f46f5f3e2"}],"children":[{"marks":[],"text":"The COVID-19 pandemic has reshaped trends in ADHD treatment, with heightened demands on attention and expanded access to telehealth contributing to an increase in adult diagnoses, according to an article in ","_key":"59bfd12c96550","_type":"span"},{"text":"JAMA Psychiatry","_key":"67a5fd547f7d","_type":"span","marks":["em","be1f46f5f3e2"]},{"marks":[],"text":".","_key":"e41352e79124","_type":"span"},{"_type":"span","marks":["superscript"],"text":"1","_key":"0f24209a1b34"},{"_type":"span","marks":[],"text":" However, diagnosing ADHD in adults remains complex. Originally perceived as a childhood disorder, ADHD is now recognized as a lifelong condition, affecting an estimated 2.5% to 4% of adults in the US and costing over $100 billion annually. ","_key":"2643ce3ee50b"}],"_type":"block"},{"markDefs":[],"children":[{"_key":"517cf6af732e","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"4b5e052d5313"},{"children":[{"_type":"span","marks":[],"text":"Diagnostic criteria—adapted from pediatric guidelines—may not adequately capture adult-specific symptoms, such as deficits in executive function or challenges in emotional regulation. This can lead to potential misdiagnosis or underdiagnosis, the authors explained.","_key":"4ce07470b51d"}],"_type":"block","style":"normal","_key":"2c32d82ee491","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"","_key":"3b012f74fcee"}],"_type":"block","style":"normal","_key":"e187f291d547","markDefs":[]},{"_key":"178aba3450e2","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Accessing treatment presents numerous challenges for many adults. Concerns about medication misuse, social stigma, and a lack of long-term data on treatment outcomes complicate care. Another challenge is that health systems, clinicians, and policy makers are grappling with how to balance the benefits of effective treatment against the risks of diversion and stimulant use disorder. ","_key":"30223e6e6e06"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"b59a9a26aff6","markDefs":[],"children":[{"text":"","_key":"ce57644173fb","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Stimulants are widely regarded as the most effective treatment for ADHD, although nonstimulants and behavioral therapies are often underutilized, the authors argued. The absence of evidence-based treatment guidelines further undermines clinicians’ confidence in prescribing, resulting in risks of both overtreatment and undertreatment. Moreover, medication shortages have highlighted disparities in access to care. ","_key":"8afe79205613"}],"_type":"block","style":"normal","_key":"11a5800c1fb6"},{"_key":"f147de34f907","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"89afb5683ca2"}],"_type":"block","style":"normal"},{"style":"normal","_key":"491b229c0225","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In September, the federal Drug Enforcement Agency (DEA) approved a production increase for Vyvanse (lisdexamfetamine) and its generic equivalents, raising the aggregate production quota (APQ) for the stimulant medication by approximately 24%.","_key":"07604e9633430"},{"_type":"span","marks":["superscript"],"text":"4","_key":"1b254f35d9ac"},{"_type":"span","marks":[],"text":" This decision aimed to address the rising demand for ADHD and binge-eating disorder treatments. ","_key":"6dfea327d993"}],"_type":"block"},{"_key":"d1b3abffba06","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"ca377fd0f867"}],"_type":"block","style":"normal"},{"style":"normal","_key":"f66566596407","markDefs":[],"children":[{"_type":"span","marks":[],"text":"However, discussions on the topic haven't led to confidence in the ability to significantly alleviate the ongoing stimulant shortage, with many largely attributing the issue to DEA-imposed production caps.","_key":"58d580d153f0"}],"_type":"block"},{"_type":"block","style":"normal","_key":"96ede933f1bc","markDefs":[],"children":[{"marks":[],"text":"","_key":"6ff0d10f3883","_type":"span"}]},{"_key":"62ef3d0b65df","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Vyvanse, which became available as a generic in August 2023, converts to dextroamphetamine in the body, the same active ingredient in Adderall. While the DEA also raised the APQ for dextroamphetamine by 18%, only about 25% of the increased quota will be allocated for domestic use, equating to just a 6.5% rise in lisdexamfetamine supply for the US. Despite higher demand—estimated by the FDA to have grown 6% from 2023 to 2024—the production adjustment falls short of bridging the supply gap.","_key":"5c59c256d39b0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"ac186627d64a"}],"_type":"block","style":"normal","_key":"ba9c4739cd48"},{"children":[{"_key":"60e3f12555b90","_type":"span","marks":[],"text":"The stimulant shortage began with Adderall supply issues in October 2022 and has since impacted other ADHD medications like Vyvanse and Ritalin. Although some Adderall manufacturers, like Teva Pharmaceuticals, have made progress in recovering inventory, Vyvanse's manufacturers and its generics face persistent challenges. The DEA’s caps on dextroamphetamine, cited as the primary reason for shortages, limit manufacturers’ ability to meet demand even after Vyvanse’s patent expired and generic versions became available."}],"_type":"block","style":"normal","_key":"acc3481c0c81","markDefs":[]},{"style":"normal","_key":"4d1407432ae1","markDefs":[],"children":[{"marks":[],"text":"","_key":"c97d692d3e74","_type":"span"}],"_type":"block"},{"_key":"9995a5001a71","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The DEA and FDA have acknowledged the challenges but emphasize their limited authority, stating they cannot mandate pharmaceutical companies to produce more or alter distribution practices. Critics argue that the DEA’s yearly quotas, described as arbitrary and restrictive, are a root cause of the ongoing shortages. Adjustments to these caps, they claim, could resolve the supply issues without requiring additional regulatory intervention.","_key":"ef0728034da70"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"eb3cb1f1fcc0"}],"_type":"block","style":"normal","_key":"f3d653f73090"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"However, William Dodson, MD, LF-APA, stated in a blog post for ADDitude that the system utilized by the DEA is designed to combat potential abuse and, therefore, is inflexible and unable to adapt to changing patient needs.","_key":"922c166c647c"},{"_key":"0abe7a7b0cf5","_type":"span","marks":["superscript"],"text":"5"},{"_type":"span","marks":[],"text":" The DEA establishes annual production caps for each pharmaceutical company based on predictions made nearly 2 years in advance.","_key":"221abc48d9f1"}],"_type":"block","style":"normal","_key":"4e066100115d"},{"_type":"block","style":"normal","_key":"86d0fe6057a9","markDefs":[],"children":[{"text":"","_key":"b961cc998cd7","_type":"span","marks":[]}]},{"children":[{"_type":"span","marks":[],"text":"\"By inviting public testimony on the stimulant shortage and pharmaceutical practices, I believe the FTC [Federal Trade Commission] is only trying to find cover for the [DEA],\" Dodson wrote. \"The DEA is the only governmental agency that sets production and distribution quotas for every drug company manufacturing controlled medication. The DEA decides how much of each medication can be released to pharmacies in any given month. Therefore, this problem traces its roots and long tendrils back to the DEA alone. No other agency has the authority to create and prolong it.\"","_key":"404e272771cc0"}],"_type":"block","style":"normal","_key":"b1ae7a627aa3","markDefs":[]},{"markDefs":[],"children":[{"text":"","_key":"8bc71841299b","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"bdcc2f225395"},{"children":[{"text":"Critics noted that the DEA’s 2022 decision to impose tighter quotas on ADHD medications stemmed from concerns about diversion and misuse—despite limited evidence supporting these claims. Dodson further explained that research has suggested that most stimulant misuse occurs among a narrow demographic of white male college students, not individuals with ADHD, who rely on these medications for daily functioning.","_key":"19b6c6ea1b38","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"05b94ad3b5df","markDefs":[]},{"children":[{"_key":"d1a80a9ef2da","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"5044ed86609a","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"The shortage worsened as the DEA restricted supply following a surge in adult ADHD diagnoses. Despite well-documented evidence that ADHD persists into adulthood, the DEA’s response seemingly ignored this reality, reducing medication availability as demand grew.","_key":"37b5fd52f1830","_type":"span"}],"_type":"block","style":"normal","_key":"978909f52395"},{"markDefs":[],"children":[{"_key":"062e6503179a","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"a5dbd6da9093"},{"_key":"bdf88447637b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Initially, the DEA and other agencies, including the FDA and FTC, attributed the shortage to manufacturing and raw material shortages. However, pharmaceutical companies have consistently stated they are producing as much as the DEA permits. Telemedicine clinics, cited as a contributing factor during the pandemic, accounted for only a fraction of prescriptions and have largely ceased operations. Despite these deflections, the shortage remains unresolved, causing significant disruption for patients reliant on these medications.","_key":"abea1b0769fe0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"f4d3d8a77e68","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7c9490c94690"}],"_type":"block"},{"markDefs":[],"children":[{"marks":[],"text":"Critics call for the DEA to overhaul its flawed quota system and prioritize patient needs over unfounded concerns about abuse. Without swift action, the shortage will persist into 2025, prolonging unnecessary suffering for millions. ","_key":"2aa61690976d0","_type":"span"}],"_type":"block","style":"normal","_key":"bc1b2fee7bcc"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"4b4098bd53c9"}],"_type":"block","style":"normal","_key":"2916acc927ad"},{"markDefs":[],"children":[{"_key":"8fc0ee8d1d290","_type":"span","marks":[],"text":"\"The idea that the drug companies were forgoing billions of dollars of profit was always unbelievable,\" Dodson wrote. \"Then the blame was laid on raw material shortages, but after two years, that explanation became hard to believe as well... The time has long since passed for the DEA to admit its fault and fix its broken quota system.\""}],"_type":"block","style":"normal","_key":"896ca7856733"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"951c29b84893","_type":"span"}],"_type":"block","style":"normal","_key":"004fc210ed6c"},{"_key":"393dcae6d2de","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"6713f02109cf"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"30d720abda99","_type":"span","marks":[],"text":"1. Blanco C, Surman CBH. Diagnosing and treating ADHD in adults: balancing individual benefits and population risks. "},{"_type":"span","marks":["em"],"text":"JAMA Psychiatry.","_key":"0726677769ae"},{"marks":[],"text":" Published online October 23, 2024. doi:10.1001/jamapsychiatry.2024.3228","_key":"cc4a4370094d","_type":"span"}],"_type":"block","style":"normal","_key":"8fbf1254a7cc"},{"_key":"2001472a2b67","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://dps.fda.gov/drugshortages","_key":"965d94f685a0"}],"children":[{"_type":"span","marks":[],"text":"2. FDA drug shortages. FDA. Accessed November 25, 2024. ","_key":"66c307bda7ce0"},{"marks":["965d94f685a0"],"text":"https://dps.fda.gov/drugshortages","_key":"44e14fa6a277","_type":"span"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"a51312c42881","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.fiercepharma.com/manufacturing/tevas-adderall-makes-it-fda-shortage-list-while-generic-adhd-med-supply-squeeze","_key":"ceae94301588"}],"children":[{"_type":"span","marks":[],"text":"3. Teva's Adderall makes it off the FDA shortage list while generic ADHD med supply squeeze persists. Fierce Pharma. May 22, 2024. Accessed November 26, 2024. ","_key":"51247e1ab429"},{"text":"https://www.fiercepharma.com/manufacturing/tevas-adderall-makes-it-fda-shortage-list-while-generic-adhd-med-supply-squeeze","_key":"e1d27d151cbc","_type":"span","marks":["ceae94301588"]}]},{"children":[{"text":"4. Wolkoff Wachsman M. Vyvanse shortage update: DEA OKs expanded production of the ADHD medication. ADDitude. 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This move marks perhaps one of the final health policy initiatives of Biden’s presidency. The new policies put forth in the plan would take effect in existing programs in 2026, expanding drug access to many who lack this coverage.","_key":"181a6f5eec21"},{"_type":"span","marks":["superscript"],"text":"1,2","_key":"40ea2329030c"}],"_type":"block","style":"normal","_key":"aefd511f5a20"},{"children":[{"_type":"span","marks":[],"text":"","_key":"ba774a3cf4a70"}],"_type":"block","style":"normal","_key":"92d28b039c32","markDefs":[]},{"disableLightBox":true,"asset":{"_ref":"image-6d57708d4b82e1880c72625d8db04dde75570664-6720x4480-jpg","_type":"reference"},"widthP":30,"_type":"figure","alt":"The FDA has previously approved these weight loss drugs for long-term use: liraglutide (Saxenda), orlistat (Xenical, Alli), bupropion-naltrexone (Contrave), phentermine-topiramate (Qsymia), semaglutide (Wegovy, Ozempic) and Tirzepatide (Zepbound, Mounjaro) | image credit: Sergej Gerasimov - stock.adobe.come","imgcaption":[{"markDefs":[],"children":[{"marks":[],"text":"The FDA has previously approved these antiobesity drugs for long-term use: liraglutide (Saxenda), orlistat (Xenical, Alli), bupropion-naltrexone (Contrave), phentermine-topiramate (Qsymia), semaglutide (Wegovy, Ozempic), and Tirzepatide (Zepbound, Mounjaro) | image credit: Sergej Gerasimov - stock.adobe.com","_key":"8feaecdcc0d6","_type":"span"}],"_type":"block","style":"normal","_key":"795d23da6e49"}],"_key":"6d55aa04f065","alignment":"right","disableTextWrap":false},{"children":[{"_type":"span","marks":[],"text":"“Increases in the prevalence of obesity in the United States and changes in the prevailing medical consensus towards recognizing obesity as a disease since the beginning of the Part D program in 2006 have compelled CMS to re-evaluate Part D coverage of anti-obesity medications (AOMs) for Medicare Part D enrollees with obesity,” the proposal writes, highlighting circumstances “where the drug’s prescribed use is not for a medically accepted indication (MAI) that is currently covered under Part D.” If made official, pending an endorsement from the Trump administration, their reevaluation would carry important implications for Part D beneficiaries.","_key":"018b7fae5fd80"}],"_type":"block","style":"normal","_key":"d6807ac35422","markDefs":[]},{"style":"normal","_key":"115aeb272a94","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"bbf68c2acd4c0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"AOMs have demonstrated great safety and efficacy throughout numerous randomized controlled trials (RCTs) over the years, as indicated by a 2021 literature review.","_key":"9fbd3296f2c00"},{"_key":"c90844901615","_type":"span","marks":["superscript"],"text":"3"},{"_type":"span","marks":[],"text":" This analysis surveyed 35 RCTs featuring robust data on 5 AOMs FDA-approved for long-term use: liraglutide (Saxenda), orlistat (Xenical, Alli), bupropion-naltrexone (Contrave), phentermine-topiramate (Qsymia), and semaglutide (Wegovy). Liraglutide and semaglutide in particular are members of the glucagon-like peptide 1 (GLP-1) receptor agonist class that has revolutionized obesity management in recent years. Despite their well-documented impact on weight loss and minimal rates of serious adverse events, decades-old legislation has prevented Medicare Part D’s coverage from extending to “weight loss” drugs, no matter that the medications are intended to treat the disease of obesity.","_key":"b3753a4501e1"},{"_key":"ecf6f6127b1e","_type":"span","marks":["superscript"],"text":"1"}],"_type":"block","style":"normal","_key":"c8221c1fa3f1"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a0b429f7d5360"}],"_type":"block","style":"normal","_key":"e441c246535d"},{"style":"normal","_key":"bcc75e0ea1be","markDefs":[],"children":[{"text":"The new proposal aims to reinterpret this ruling to allow plan coverage of AOMs when their purpose is to address a patient’s obesity and long-term weight management to hopefully prevent associated complications, comorbidities, and conditions. 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\"MMR vaccine\", \"thimerosal\"]}","ExcludeFromPubMedXML":false,"_updatedAt":"2024-11-25T20:20:48Z","is_visible":true,"factCheckAuthors":null,"articleType":"News","documentGroup":null,"gptTakeaways":"• Dave Weldon, a vaccine critic, is nominated for CDC Director, potentially shifting vaccine safety responsibilities away from the CDC.\n\n• Marty Makary, a critic of COVID-19 mandates, is nominated for FDA Commissioner, aiming to address pharmaceutical and insurance influence.\n\n• Janette Nesheiwat, an advocate for COVID-19 vaccination, is nominated for Surgeon General, potentially causing cabinet division on vaccine mandates.\n\n• These nominations follow Trump's controversial picks of Robert F. Kennedy Jr. as HHS Secretary and Mehmet Oz for CMS.","authors":[{"displayName":"Maggie L. Shaw","url":"maggie-l-shaw"}],"gptSummary":"President-elect Donald Trump has nominated Dave Weldon, Marty Makary, and Janette Nesheiwat for key healthcare positions in his administration. Weldon, a former congressman and vaccine critic, is nominated for CDC Director. Makary, a public policy researcher and critic of COVID-19 mandates, is nominated for FDA Commissioner. Nesheiwat, an advocate for COVID-19 vaccination, is nominated for Surgeon General. These nominations follow Trump's controversial picks of Robert F. Kennedy Jr. as HHS Secretary and Mehmet Oz for CMS. All nominees must undergo confirmation hearings.","_type":"article","_createdAt":"2024-11-25T19:14:39Z","thumbnail":{"_type":"mainImage","alt":"Governmentgraphic | Image Credit: © Egor-stock.adobe.com","asset":{"_ref":"image-0db49c35d2b2fca45515dda034b8cb45fa017ede-1200x738-jpg","_type":"reference"}},"factCheckAuthorMapping":null,"_rev":"I64rexdokWxpEDPZsip6tT","body":[{"_key":"90231e66403a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Former Rep Dave Weldon, MD (R, Florida); Marty Makary, MD, MPH; and Janette Nesheiwat, MD, have been nominated to fill key health care positions in President-elect Donald Trump’s second administration as head of the CDC, FDA Commissioner, and US Surgeon General, respectively. They could potentially step into these roles when Mandy K. Cohen, MD, MPH; Robert M. Califf, MD, MACC; and Vivek H. 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Powel J. Who has Trump picked for his Cabinet? Brooke Rollins rounds out nominees. USA Today. November 24, 2024. Accessed November 25, 2024. ","_key":"10872ccf4c140"},{"_type":"span","marks":["197a74628a27"],"text":"https://www.usatoday.com/story/news/politics/elections/2024/11/24/donald-trump-cabinet-picks/76548459007/","_key":"10872ccf4c141"}],"_type":"block","style":"normal","_key":"20572e7af8ed","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.usatoday.com/story/news/politics/elections/2024/11/24/donald-trump-cabinet-picks/76548459007/","_key":"197a74628a27"}]},{"_type":"block","style":"normal","_key":"c8ad81af4628","markDefs":[{"blank":true,"_type":"link","href":"https://www.ajmc.com/view/trump-selects-dr-oz-as-cms-administrator","_key":"678b41d85843"}],"children":[{"_type":"span","marks":[],"text":"2. Jeremias S, McCormick B. Trump selects Dr Oz as CMS administrator. ","_key":"4b96544cd9870"},{"_type":"span","marks":["em"],"text":"AJMC","_key":"4b96544cd9871"},{"_key":"4b96544cd9872","_type":"span","marks":["superscript"],"text":"®"},{"_type":"span","marks":[],"text":". November 19, 2024. Accessed November 25, 2024. ","_key":"a8fc9a9ed017"},{"marks":["678b41d85843"],"text":"https://www.ajmc.com/view/trump-selects-dr-oz-as-cms-administrator","_key":"4d81f7dd9f360","_type":"span"}]},{"children":[{"_type":"span","marks":[],"text":"3. Mattina C. Trump announces RFK Jr as HHS secretary pick","_key":"e4a6daa3ebe90"},{"_type":"span","marks":["em"],"text":". AJMC","_key":"e4a6daa3ebe91"},{"text":". November 19, 2024. Accessed November 25, 2024. ","_key":"e4a6daa3ebe92","_type":"span","marks":[]},{"_type":"span","marks":["cd587bf4f506"],"text":"https://www.ajmc.com/view/trump-announces-rfk-jr-as-hhs-secretary-pick","_key":"e925adfab741"}],"_type":"block","style":"normal","_key":"d0ce1155292a","markDefs":[{"_key":"cd587bf4f506","nofollow":false,"blank":true,"_type":"link","href":"https://www.ajmc.com/view/trump-announces-rfk-jr-as-hhs-secretary-pick"}]},{"_key":"fd5e4b2721ef","markDefs":[{"nofollow":false,"blank":true,"_type":"link","href":"https://www.ajmc.com/view/support-and-skepticism-emerge-as-reactions-to-robert-f-kennedy-jr-s-hhs-nomination","_key":"2e6fc3b227f6"}],"children":[{"_type":"span","marks":[],"text":"4. Joszt L. Support and skepticism emerge as reactions to Robert F. Kennedy Jr’s HHS nomination. ","_key":"3378d61d2e2a0"},{"_type":"span","marks":["em"],"text":"AJMC","_key":"3378d61d2e2a1"},{"text":". November 15, 2024. Accessed November 25, 2024. ","_key":"3378d61d2e2a2","_type":"span","marks":[]},{"marks":["2e6fc3b227f6"],"text":"https://www.ajmc.com/view/support-and-skepticism-emerge-as-reactions-to-robert-f-kennedy-jr-s-hhs-nomination","_key":"1f37a7a9e785","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.cdc.gov/museum/history/pastdirectors.html","_key":"f79b10101bd9"}],"children":[{"_type":"span","marks":[],"text":"5. Past CDC director/administrators. CDC. Accessed November 25, 2024. ","_key":"f8011c39faba0"},{"text":"https://www.cdc.gov/museum/history/pastdirectors.html","_key":"f8011c39faba1","_type":"span","marks":["f79b10101bd9"]}],"_type":"block","style":"normal","_key":"dc914905ff06"},{"markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://truthsocial.com/@realDonaldTrump/posts/113529510778344338","_key":"4f3017c8a1d2"}],"children":[{"_type":"span","marks":[],"text":"6. Statement from President Donald J. Trump. 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The only decrease was seen in 2020 when it was 10.1%, though this was sandwiched between a rate of 10.2% the year before and 10.5% the year after.","_key":"9c868c95bc220"}],"_type":"block","style":"normal","_key":"5508913e33f5","markDefs":[]},{"_type":"block","style":"normal","_key":"1f59da7d61e3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a90d18eb03520"}]},{"style":"normal","_key":"10a331aef881","markDefs":[],"children":[{"marks":[],"text":"Vermont received the only A grade in the country, with a preterm birth rate of 7.7%. 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Only 4 of these states landed in the A range: Ramapo, New York (5.2%); Irvine, California (7.0%); Gilbert, Arizona (7.8%); and Seattle, Washington (8.1%).","_key":"3a80748a539a0"}]},{"_key":"2f079914c643","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"980df79828640"}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.ajmc.com/topic/center-on-health-equity-and-access","_key":"0b0a4fde76d4","nofollow":false}],"children":[{"text":"The report card highlighted ","_key":"4533f2f60a310","_type":"span","marks":[]},{"_key":"f85136f56ad9","_type":"span","marks":["0b0a4fde76d4"],"text":"racial disparities"},{"text":" in birth outcomes, with Black birthing people continuing to experience significantly worse maternal outcomes in the US. The preterm birth rate for this population was 1.4 times higher than for all others at 14.7%; Pacific Islander and American Indian/Alaska Native birthing people both had failing rates of 12.4%. 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Maternal mortality returned to prepandemic levels in 2022, with over 800 maternal deaths, with clear racial disparities persisting.","_key":"f64ea40307f60"}],"_type":"block","style":"normal"},{"children":[{"marks":[],"text":"","_key":"e3e37a327e960","_type":"span"}],"_type":"block","style":"normal","_key":"8f51ff957f49","markDefs":[]},{"_type":"block","style":"normal","_key":"085accb907a2","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The Black infant mortality rate was 10.6—nearly double the national average of 5.6—and this rate was again higher for Pacific Islander and American Indian/Alaska Native birthing people. 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