Social determinants of health (SDOH) sit at a strange place in federal healthcare payment models. In early 2024, Medicare added a CPT code set for physician payment to address health-related social needs of Medicare beneficiaries, specifically Caregiver Training Services (CTS), Community Health Integration (CHI) services, Principle Illness Navigation services (PIN), and Social Determinants of Health Risk Assessment (SDOH RA). The codes are limited and highly specific, and often as a result, overlooked or de-prioritized. But you don’t need CPT codes or risk adjustable HCC codes to deliver a significant impact on cost of care and clinical outcomes.
The right partner can deliver unmatched social insights at a highly granular level that, when combined with payer claims data, allows for highly specific opportunities for interventions that deliver a substantial cost savings and improve quality of life for members.
That’s why at Socially Determined, we pay very close attention to policy and technical updates from CMS.
Let’s get into it.
Last week, CMS announced an estimated 5.06% increase in MA payment revenue CY 2026. The increase is notably higher than prior years (3.7% in CY 2025, 3.32% for CY 2024). The 5.06% translates to a $25 billion increase.
The announcement is largely consistent with the Advance Notice, except for an elimination of a Biden-administration rule around oversight and the coverage of obesity medication. Additionally, because rate calculations were not available for CY 2023, the Oncology Care Model and Enhanced Oncology Model are not included in this recalculation.
So, where do social determinants of health come into play in Medicare Advantage?
Traditionally, best possible coding, adherence to quality measures, and similar careful participation in CMS’s payment models leads to the best way to ensure complete, accurate payments and, by extension, reduce costs through diligent care.
However, the revenue increase presents a notable opportunity to explore additional opportunities that yield even further sustainable clinical and financial returns.
Social determinants of health impact 30-55% of all health outcomes, this is especially true among populations covered by Medicare, Medicaid, Medicare Advantage, and ACA marketplace plans. From a quality perspective, lack of access to transportation and good nutrition alone can lead to significant chronic disease progression, readmission rate, and unnecessary ED visits, not to mention more complicated events under the new episodic care model.
It's safe to say the main reason these factors aren’t top of mind for optimizing participation in these programs by payers comes down to a difficulty in discerning outcomes and ROI through a lack of effective targeting.
That’s where Socially Determined comes in. We’re the only strategic partner that can identify beneficiaries at high social risk and precisely what that risk is. There’s no more ad hoc guess work, no more advertising a program broadly and settling for minimal beneficiary participation.
SDOH Don’t Have to Be Out of Reach for Medicare Advantage Beneficiaries
When a payer partners with Socially Determined for long term strategic development of intervention plans, they’re bringing on experts that can deliver something unique in healthcare: ongoing insights that, when combined with in-house claims data, allows for the expert-guided selection of actuarially verified opportunities to intervene. Those interventions are targeted, active, and deliver real results for specific beneficiaries at scale. It leads to improvements in member quality of life, and significant improvements in SDOH-influenced clinical factors that drive costs and penalize the risk-holder for that patient’s care despite them (previously) being outside of reach for clinicians.
You’re already doing your best to reduce costs and improve outcomes. However, closing the substantial gaps in cost and outcomes caused by social determinants of health has always sat out of reach. They’re not anymore.
What would your cost and beneficiary health look like if you knew exactly how to reduce inpatient stays associated with type II diabetes (T2DM) by an additional 63%? A 50% increase in medication adherence? A 58% in ED visits?What about a 3.5k PMPM savings for ESRD patients just by knowing exactly which members to provide with rides to dialysis?
If you’re ready to find out how much healthier your population can be and to bring an end to SDOH driving costs out of reach regardless of your MA payment arrangement, it’s time we had a conversation.