Leveraging SDOH Data to Improve Health Equity in Value-Based Care

In the transition from fee-for-service to value-based care (VBC) models, addressing health equity has become a crucial goal. The focus is shifting from providing equal care to providing equitable care, recognizing that different populations have unique needs. Incorporating social determinants of health (SDOH) data into VBC initiatives can help identify disparities and drive action towards improving patient outcomes and reducing healthcare costs. This article explores the significance of SDOH data in VBC models and highlights the role of technology in collecting, analyzing, and leveraging this data for better care.

Understanding Equality vs. Equity

Equality means providing the same care to everyone, but equity involves providing care based on individual needs. Recognizing the diverse backgrounds and circumstances of patient populations is essential for delivering equitable care. To ensure equitable care, it is crucial to collect and analyze SDOH data to understand patients’ unique requirements and design personalized care plans accordingly.

ACO REACH Model and Health Equity

The ACO REACH model stands out as an example of incorporating health equity benchmarks by utilizing SDOH data. This model rewards providers for caring for patients in the top 10th deciles of the area deprivation index. This approach encourages healthcare organizations to focus on addressing disparities and providing targeted support to underserved populations.

The Role of Technology in Collecting and Analyzing SDOH Data:

Technology plays a pivotal role in efficiently collecting and analyzing SDOH data to inform care decisions. The ability to capture data at the point of care empowers healthcare providers to identify patients’ needs, including social, psychological, and economic factors. By leveraging advanced platforms, healthcare organizations can bring together disparate data sources, enable interoperability, and gain a comprehensive view of patients’ social determinants of health.

Impact on Total Cost of Care

A significant aspect of VBC models is managing the total cost of care. SDOH data can help healthcare organizations identify patients who require additional support, such as housing or food assistance, to address underlying social determinants affecting their health. By connecting patients with appropriate resources and interventions, healthcare providers can prevent costly emergency room visits, hospital readmissions, and unnecessary medical expenses. Taking a biopsychosocial approach to patient care can lead to better outcomes and reduced costs.

Collaboration between Payers and Providers

Collaboration between payers and providers is essential for the success of health equity initiatives. By aligning their interests and working together, both parties can develop comprehensive plans and strategies to address disparities in care. Sharing standardized data is a key challenge that needs to be overcome to enable effective collaboration. Healthcare organizations should invest in platforms that facilitate data integration, provide actionable insights, and support evidence-based decision-making.


In the transition to VBC models, addressing health equity is of paramount importance. Technology plays a crucial role in collecting, analyzing, and leveraging SDOH data, enabling healthcare providers to make informed decisions at the point of care. Ultimately, leveraging SDOH data in VBC models offers a promising pathway towards a more inclusive and effective healthcare.

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