Socioeconomic disparities in health outcomes have proven to be persistent in the United States. For example, the mortality rate for Black infants is twice as high as it is for white infants, and low-income children are more likely to experience developmental delays as compared with their peers.1 Emerging data reveal striking racial and socioeconomic inequities in coronavirus disease 2019 outcomes. Healthy People, the national framework for population health, has identified reduction of health disparities and achievement of health equity as crucial goals. However, despite substantial investments, the nation is no closer to achieving these key societal aims, with alarming evidence of widening health disparities in recent years.2
Over the past decade, the US health care delivery system has undertaken a large-scale transformation aligned with achieving the triple aim (improving quality, reducing costs, and enhancing experience of care).3 Pediatricians have made important investments in quality improvement, medical home certification, primary care redesign, and electronic health record adoption to advance these aims. The financing of pediatric care has also evolved with a rapid movement toward value-based care (VBC), whereby pediatricians receive incentives for lowering costs and improving quality. In 2016, approximately half of pediatricians participated in VBC, and that amount has likely increased in recent years.4 Pediatric VBC programs are often focused on addressing the social determinants of health (SDOHs) that strongly correlate with adverse physical, emotional, and developmental outcomes in children. Examples include incentives for conducting universal SDOH screenings, referrals to community-based organizations, and administration of social supports. VBC aims to enable more proactive care delivery by helping pediatricians make up-front investments in SDOH services and supports, which are sustained with downstream savings from reductions in costs. The intersection of VBC and SDOHs represents an important new paradigm for pediatricians with vast potential for improving health for socioeconomically disadvantaged children. However, if access to these new services is unequal, there becomes an inherent risk of unintentionally exacerbating existing inequities. In this article, we outline core constructs that are essential to identifying and addressing SDOHs in VBC programs, those of surveillance, referral, and supports, and examine how applying an equity lens can help advance child health at the population level.
SDOH Surveillance and Referral
Pediatricians regularly assess the psychosocial needs of children as part of routine care. Some insurers, as part of VBC, have started to financially incentivize practitioners to conduct universal screening for SDOHs by using structured screening tools. Although well intended and likely to benefit many children, the current approach risks contributing to unequal recognition of basic needs across the population. First, most VBC initiatives are unique to a single insurer, often Medicaid,5 with little regional collaboration with private insurers. Although publicly insured children often experience higher levels of unmet needs, this approach risks missing many low- and middle-income privately insured families who also experience unmet social needs. This is particularly relevant during the coronavirus disease 2019 pandemic when many working families have experienced economic adversity. Defining screening interventions by insurance status also creates a challenging dilemma for practitioners who are left deciding between incurring the added costs of nonreimbursed population-wide screening, which can be time and resource intensive, or limiting access to screening on the basis of insurance status, neither of which is ideal. Second, not all screening tools used to identify SDOHs are well validated in highly diverse populations.6 This may contribute to under-recognition of SDOHs in families from cultural groups not included in the initial design and testing of the screening tool. Third, the availability of community-based supports for referrals is often unequal on the basis of geography, transportation, and language, leading to unequal access to services as well as hesitance by some pediatricians to participate in screenings.7 For example, pediatricians in rural communities, where the availability of community-based supports can be more limited than in metropolitan areas, may find universal screening mandates more challenging to implement ethically. Pediatricians can apply an equity lens by identifying screening instruments that meet the linguistic and cultural needs of their populations, working to build strong and respectful community-based partnerships with organizations serving people of diverse backgrounds, and advocating with local insurers and policy makers about the importance of regional approaches to SDOH screening and referral.
In recent years, pediatric practices, delivery systems, and hospitals participating in VBC have started investing in food, cell phones, transit passes, and even housing assistance to administer to patients. Ensuring equitable allocation of these limited (and expensive) supports is a new frontier for many practitioners. Few evidence-based protocols exist to guide enrollment, dose, and duration for social supports, especially when contrasted with more established medical interventions. For example, in caring for a homeless infant with chronic lung disease, a pediatrician will find more direction for monoclonal antibody treatment as compared to temporary housing assistance, although both are expensive and impactful therapies for preventing bronchiolitis. Absent evidence-based protocols for SDOH services, clinicians may make these decisions on the basis of best clinical judgement or employ decision-making heuristics that can be susceptible to unconscious implicit bias, inadvertently contributing to inequitable distribution of services. Some VBC programs use data algorithms to identify children with high costs and preferentially administer SDOH supports to them in an effort to reduce health costs. However, this highly efficient approach risks misclassifying children whose unmet basic needs do not immediately manifest in high health costs. In addition, adult studies reveal that racial bias exists in some data algorithms used to identify high-cost patients, although it is unclear if this also occurs in children.8 Moving beyond high cost as a means for identifying service recipients and instead focusing on shared polysocial risk scores may support more equitable access.9 Pediatricians can also apply an equity lens by closely tracking which patients receive supports and proactively identifying inequities in allocation of investments.
The model of VBC provides opportunities for more coordinated activity among pediatricians, insurers, and policy makers to better identify and address SDOHs. Pediatricians are encouraged to monitor their own performance in an attempt to ensure that all children can equally access and benefit from new SDOH services. Policy makers are encouraged to allocate funding to support pediatricians in collecting more accurate and wider-ranging SDOH data, similar to programs that have been historically successfully in increasing electronic health record and medical home rates. Insurers are encouraged to regionally collaborate on VBC and SDOH screening initiatives, such as those occurring in some areas of the country as part of the Medicare Comprehensive Primary Care Initiative.10 Regional partnerships should set the reduction of health disparities as an explicit goal, with financial incentives given to pediatricians who both improve quality overall and reduce disparities. Ultimately, employers and governments will bear the initial costs of these up-front investments. However, reducing disparities in chronic illness incidence and severity has the potential to lower health expenditures over the long run while providing a positive societal return on investment through improved social equity at the population level.11
VBC is at the forefront of pediatric health care delivery with vast potential for improving health outcomes for socioeconomically disadvantaged children. However, if disparities exist in access to SDOH screening, referral, and supports, there is a risk of widening certain health inequities. Placing a health equity lens on the design and implementation of VBC initiatives aimed at ameliorating unmet basic needs will help ensure that all children can benefit equally.
Dr Peltz drafted the initial manuscript; Mr Rogers and Dr Garg helped conceptualize the initial manuscript; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
social determinant of health
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr Peltz discloses consulting services to the Yale New Haven Hospital and the Centers for Medicare and Medicaid Services in development of methods for evaluating disparities in Medicare quality. This work is not related to the article, and these entities were not involved in any aspect of this article; and Mr Rogers and Dr Garg have indicated they have no financial relationships relevant to this article to disclose.