Addressing the Social Determinants of Health in Program, Payment, and Policy: Extrapolating the Triple Aim for Population Health

There is much more to being healthy than traditional health care. In fact, “health care” is a surprisingly minor factor in health and the prevention of premature death, just 10 percent. Social circumstances, environmental exposures, genetic predisposition, and personal behavior combined contribute to 90 percent of preventable deaths.1 Unfortunately, trying to design, deliver, and be paid for these non-treatment factors is extremely difficult, but critical if we truly want to improve the health outcomes for the largely poor and socially marginalized people in our programs.

In his instructive 1997 book Purchasing Population Health: Paying for Results, David Kindig notes that population health goes beyond aggregate health outcomes for a group of people, and must take place “in an economic framework that balances the relative marginal returns from the multiple determinants of health.” This definition speaks to the reasons why Medicaid and other health care financing systems ignore social determinants to a large degree: there are so many factors that go into the way people achieve well-being that paying for each of them would yield relatively marginal returns compared to the more discretely measurable elements of acute care.

So how can actors in the traditional system of care take into account the vast array of experiences that promote well-being? Encouraged by the Affordable Care Act’s focus on the “Triple Aim” of health care (better population-based health outcomes, better quality care, and lower cost), state health agencies, insurers, providers, and health networks are all looking at how to improve an overall experience of well-being for participants while incentivizing an economic framework that reduces costs.

In pursuit of the ACA’s Triple Aim, policymakers, payers, and providers can adopt a three-tiered approach to population health. First, all actors should focus on a range of options that promote well-being and meet the needs of the people they work with. Second, social determinant options should be complemented by a range of supports with discrete and measurable quality indicators. Third, these practices should be supported by financial mechanisms that invest in the entire range of health promotion activities, and managed by people with a vision that supports whole-health activation.

Community Access has supported social determinants toward population health since its inception. The conviction that a safe and stable home environment – that afforded individuals independence and space to account for the dignity of personal risk and accountability – evolved into a 42-year mission of offering housing as a first step toward achieving community well-being.

Today, Community Access participants are encouraged to utilize a multitude of options that improve their health. In 2002 we initiated a pet adoption program called Pet Access when employees realized how beneficial the support of dogs and cats is to people who live in our apartments. Pet ownership is well known to promote quality of life and even a longer lifespan, but it also encourages sociability and self-reliance. Similar motivations led to the creation of the Art Collective, where participants learn and practice artistic skills and are supported in entrepreneurial efforts to sell artwork for profit. In 2015 an expert in urban gardening joined the Community Access team to build gardens in the backyards of Manhattan and Bronx housing sites, and to help participants and families grow, cook, and use food harvested by hand. In the spring of 2016, we are introducing a fleet of bicycles at one of our Bronx housing locations that participants can use for exercise, group activities, or traveling to the grocery store or health care appointments.

Promoting social determinants at Community Access is balanced by community approaches that yield discrete and measurable outcomes. We offer supports that are now being encouraged within a Medicaid framework: a growing health division that teams care managers with population health experts who can train staff and support participants in whole-health management; education support services for people having trouble in post-secondary school and training or wanting to achieve a high school degree; workforce development for peers who want to work in human services and position for radical change in the health care system; and crisis respite that promotes community resilience and recovery while reducing the enormous financial and personal toll of a hospital stay.

Alongside these community supports are robust financial, administrative, and quality assurance mechanisms. Our strategy depends upon: a quality assurance team working closely with all programs to design an environment that is favorable to the whole-health experiences and outcomes of participants; a human resources department that affirmatively hires people with lived mental health experience and removes the barriers to employment that service users often experience; and a development team that focuses on strategic planning and communications to attract a broad range of donors. Additionally, central to our mission is self- and systems-advocacy work. Our advocacy commitments include informing city and state policy and even supporting Community Access participants to address shortcomings within our programs.

Policymakers can adopt these approaches too, for the benefit of Medicaid members. Non-provider stakeholders can ensure that ample opportunities are afforded for social determinant expansion alongside more traditional integrated health care approaches, all supported by administrative and financial mechanisms that recognize the value of paying for population health.

For example, Managed Care Organizations (MCOs) can be optimal partners for community-based providers, because insurance companies appreciate that strategic innovation can save money by improving health-related concerns. Partnerships between MCOs and providers across the country have demonstrated some of the innovative approaches – including peer community health workers and peer-run crisis respite – that are now being built systematically across New York. MCOs can continue with innovative investments by promoting new service approaches that integrate a range of social determinant solutions as well as integrated whole-health management. They can also improve by accelerating their understanding of acute responses that provide alternatives to costly Medicaid expenditures, such as more “risky” models of mobile crisis and respite.

Policymakers have made sincere efforts to take into account the abilities of community-based organizations to make an impact in the whole-health needs of New Yorkers receiving Medicaid. However, significant investments should still be made in order to achieve integration of whole-health priorities at the community level. For example, commitments by Department of Health and Office of Mental Health policymakers to reinvest savings from Medicaid Redesign initiatives back into the behavioral health field can take into account new approaches to population health. Social determinant advances can be driven by community-based providers agile enough to use reinvestment money to meet the particular needs of the communities they serve.

New York’s Value Based Payment roadmap to financial reform may be the most significant step to build incentives for community agencies to integrate population health into a single payment bundle with built-in rewards and risk. Community-based providers can prepare for this in concrete ways, by diversifying the investments they are already making in achieving health and well-being for participants and designing quality assurance processes to collect and analyze data that indicates not just relief from acute symptoms of diagnoses but that also correlate to changes in population health metrics. This shift requires intensive planning and time for administrators who have limited financial resources for investing in technology systems and a proficient workforce. New York can invest in the administrative and financial resources of its providers to prepare for this shift, as providers use shared information across systems to prepare for innovation in service delivery.

Along with investments in providers’ ability to manage value-based contracts, policymakers should support the creation of analytical software for risk assessment and modeling that takes into account social determinants of health. This is not a simple task: currently, there is no existing model that can (for example) analyze the Medicaid costs associated with an individual experiencing complex behavioral and physical health needs as well as housing instability, and project how those Medicaid costs would change if that person achieves housing stability. Instead of waiting for a software product that can achieve this, state policymakers can incent MCOs to pilot projects that test models that can account for the previous example and others that target food insecurity, social integration, early childhood trauma, and other social determinants. New York is already leading the way in Medicaid system reform, but it could also develop projects that manifest insights for the creation of the first risk projection tools that take into account population health.

The preceding examples indicate strategic ways that policymakers, payers, and providers can all make room for a focus on population health by building sustaining platforms of investment in social determinant approaches, integrated health management, and financial and administrative planning.

Population health management can take many forms for community-based providers, as well as for hospitals, MCOs, and policymakers. At Community Access, our own “triple aim” relies on a framework that positions the social determinant well-being of participants with equal importance to community-based recovery supports with discrete and measurable outcomes, and progressive administrative practices. Preparing for the policy shifts that can support this framework today and in the future has required a robust investment of staff expertise and collaboration as well as pursuit of “non-traditional” funding supports including grants and a large base of donors. But as we strategically plan and await effective policy and financial mechanisms for inclusion of social determinants, we are actively providing a range of investments into the well-being of participants today.
To learn more about how your agency can use peer-informed practice to enhance social determinant opportunities for participants while preparing for value-based system reform, contact Briana at


  1. J. Michael McGinnis, Pamela Williams-Russo, and James R. Knickman, “The Case For More Active Policy Attention to Health Promotion,” Health Affairs 21 (2) (2002): 78–93.

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