Socially Determined and Mathematica Partner to Target Social Risk for Government Organizations

The partnership seeks to highlight the impact of social determinants of health on costs and outcomes.

It will take the biggest government payers and agencies to affect the biggest changes in social drivers of health — the non-clinical factors (e.g., housing, food, transportation) that affect 80% of clinical health outcomes.

And while that process has begun through a “whole of government” approach that brings these players together (The U.S. Playbook To Address Social Determinants of Health), it will take robust SDOH data and analytics. One new collaboration may help.

Socially Determined is partnering with Mathematica to help government organizations “improve programs, refine strategies, and deepen their understanding” of SDOH. Specifically, Mathematica will look for opportunities to support its federal and state consultancy clients by applying Socially Determined’s social risk data and analytics. Desired outcomes include:

• insights into SDoH risk factors and risk exposure
• the impacts of this risk on both individuals and communities
• the downstream effects on healthcare utilization, costs, outcome, and equity.

Mathematica already works with Medicare, Medicaid, CHIP and other federal and state programs on multiple initiatives. Socially Determined’s clients include health systems, health plans, and other risk-bearing organizations.

“Mathematica and Socially Determined are remarkably aligned on our mission-driven focus and academic roots in a way that enables us to begin delivering value to clients on day one,” notes Trenor Williams, CEO and Co-Founder of Socially Determined in the partnership press release.

Breaking down silos

The Socially Determined-Mathematica partnership comes at a time when “[h]ealth and social service agency leaders are more focused than ever on breaking down silos between programs to improve wellbeing of the whole person,” notes Joshua Baker, Mathematica’s VP of State Health, in the partnership press release.

These silos are the very focus of the previously mentioned U.S. SDOH Playbook.

The Playbook states: "The frequent organizational separation of health care from services such as housing or nutrition programs complicates efforts to address interconnected health needs. This Playbook lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.”

The three pillars needed for SDOH impact

The Playbook includes three pillars:

1. Pillar 1: Expand Data Gathering and Sharing
2. Pillar 2: Support Flexible Funding to Address Social Needs
3. Pillar 3: Support Backbone Organizations

Focusing on Pillar 1, the Playbook notes that The Biden-Harris Administration is “working to improve data gathering and interoperability to address SDOH [and] . . . expand the collection of SDOH data for health research” across the federal government.

Specific objectives of Pillar 1 that can support SDOH data gathering and sharing include:

• establishing a federal data work group
• improving data collection and exchange across federal and state agencies and programs
• aligning federal agencies and community organizations for better SDOH referrals
• reducing SDOH data gaps to improve health outcomes
• identifying communities and populations with the greatest SDOH risks

The Playbook notes how these objectives will meet SDOH challenges across all three Pillars.

“Enhancing data infrastructure and interoperability (the ability to capture, share and exchange the data safely and effectively) can facilitate progress on Pillars 2 and 3 and provide data to help measure the impact of an initiative."

The Playbook adds: “Community-level data on SDOH and individual-level data on HRSNs are not routinely collected in a standardized way across both health and social care services organizations. Further, due to interoperability hurdles and in order to preserve patient privacy, data sharing among organizations can be a complex field to navigate. This limited data gathering and sharing capacity makes coordinating comprehensive care, answering key policy and programmatic questions, and supporting quality improvement efforts challenging.”

How partnerships can help

The Socially Determined-Mathematica press release notes that their “unique combination of technology, expertise, and experience” can help government organizations “understand and quantify the impact of SDoH initiatives on healthcare cost and outcomes.”

“With the high-tech and high-touch strategy that our partnership enables us to deliver, we’re in a unique position to help organizations at all levels of government implement and realize value from data-driven strategies around SDoH that they couldn’t access before,” notes Williams.

Baker adds: “The data and policy expertise brought to bear through this new partnership, combined with our reach and experience serving state and local governments, is a powerful force for public good.”