SDOH Payment Models And The Future of Reimbursement

Today’s healthcare system largely remains in the “reactive” phase of the Social Determinants of Health (SDOH) maturity model—responding to medical crises rather than addressing the social and environmental conditions that drive them. To understand the scope, it helps to know the distinction between SDOH and broader determinants of health that influence well-being. While clinicians and health systems increasingly recognize that factors like housing instability, food insecurity, and lack of transportation directly impact health outcomes, the financial infrastructure to act on this knowledge is still catching up.

A key barrier is the structure of healthcare payments. Under traditional fee-for-service models, reimbursement is tied to billable medical procedures—not the non-clinical interventions that could prevent those procedures in the first place. There’s no CPT code for services that appropriately address someone’s determinants of healtsuch as coordinating a housing placement, arranging a food delivery, or helping a patient navigate unemployment benefits. As a result, these vital services are often underfunded, inconsistently delivered, or reliant on temporary grants and community goodwill rather than sustainable healthcare dollars.

Current System Payment Models for SDOH-Related Services:

Emerging Solutions And The Path Forward

Value-based care models are beginning to shift this paradigm by tying reimbursement to outcomes, rather than volume of care. But even within many value-based arrangements, SDOH-related interventions remain underrecognized in payment methodologies. Many care teams still operate without clear mechanisms to bill for social needs assessments, community resource navigation, or coordination with social service agencies.

Some promising changes are emerging. In California, programs like CalAIM's Enhanced Care Management (ECM) and Community Supports explicitly reimburse providers for addressing social drivers of health, such as housing navigation or medically tailored meals. Medicaid waivers in other states are beginning to follow suit, piloting payments for non-traditional services that improve health and lower costs. Yet these models are not yet widespread or fully integrated across payers.

To move from reactive to proactive and ultimately to integrated phases of the SDOH maturity model, payment systems must evolve. That means creating clear, scalable reimbursement pathways for social care. It means rethinking medical necessity to include the social conditions that make medical care truly effective. Until then, addressing SDOH will remain more of a moral imperative than a funded mandate—important, but not always supported.