New Study Published in JAMA Internal Medicine Finds Substantial Resources Required to Address Social Needs Detected in Primary Care

Researchers estimate that existing federal funding covers less than half the total cost of delivering evidence-based interventions for food, housing, transportation and care coordination needs

A new study published in JAMA Internal Medicine has found that while primary care practices are increasingly screening patients for health-related social needs, the total cost of providing evidence-based interventions far exceeds federal funding for programs designed to address them. 

In this large study of 19,225 patients, researchers estimated that the cost of delivering evidence-based interventions for food, housing, transportation, and care coordination assistance averaged $60 per member per month (PMPM), of which less than half ($27) was covered through existing federal funding. These findings suggest that additional funding is required to address health-related social needs that are not being met through existing programs. 

"We know that unmet health-related social needs are associated with health disparities and poor clinical outcomes," said Sanjay Basu, MD, PhD, a senior author for the study and Co-Founder and Head of Clinical at Waymark. "But we've historically lacked an understanding of how much to adjust payments to account for social risk factors. This research fills an important gap for both policymakers and payers evaluating how much additional funding is required to address patients' health-related social needs." 

Researchers used data from the National Center for Health Statistics from 2015 through 2018 (n=19,225) to develop a microsimulation model estimating the costs of evidence-based interventions for food assistance, housing programs, nonemergency medical transportation, and community-based care coordination. Primary care practices included in the study were categorized as federally qualified health centers (FQHCs), non-FQHC urban practices in high-poverty areas, non-FQHC rural practices in high-poverty areas, and practices in lower-poverty areas.

"Jack Geiger was famous for saying that, in medical school, he learned that the best prescription for hunger was food," said Robert Phillips, MD, MSPH of the Center for Professionalism and Value in Health Care. "This study should support payers in giving clinicians a new prescription pad that costs $2.17 per patient per day—less than the cost of a cup of coffee."

The study also found that inadequate program capacity and narrow eligibility criteria may be excluding patients from federally-funded social services programs: 

  • Among people with housing needs, 78% were program-eligible but only 24% were enrolled.
  • Among people with food needs, 96% were program-eligible but only 70% were enrolled. 
  • Among people with transportation needs, only 26% were eligible for transportation programs.  
  • Among people with care coordination needs, only 6% were eligible for care coordination programs. 

"Not only are existing programs to address health-related social needs underused, but many people with these needs are not eligible for them," said Seth A. Berkowitz, MD, MPH of the University of North Carolina at Chapel Hill. "It's not just a question of navigating people into programs that already exist—we need new programs that can address the social context that is making people sick."

Additionally, the authors noted that the cost of providing universal screening in primary care practices was $5 PMPM. "Although this is far lower than the costs of delivering services, it still represents a substantial cost to primary care practices, which are already underfunded and under tremendous pressure," said Bruce Landon, MD, MBA of Harvard Medical School. "These findings suggest that more funding needs to be directed to primary care to support the implementation of more robust, comprehensive screening."

The full article titled "Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care" was published in JAMA Internal Medicine. The senior authors for this article were Sanjay Basu of Waymark and Bruce Landon of Harvard Medical School. Co-authors for this article include Seth A. Berkowitz of University of North Carolina, Caitlin Davis of Inova Health System, Connor Drake of Duke University, and Robert Phillips of the Center for Professionalism & Value in Health Care.  

About Waymark

Waymark is a public benefit company dedicated to improving access and quality of care for people receiving Medicaid. We partner with health plans and primary care providers to reduce disparities and improve outcomes through technology-enabled, community-based care. Our local teams of community health workers, pharmacists, therapists and care coordinators use proprietary data science and machine learning technologies to deliver evidence-based interventions to hard-to-reach patient populations. For more information, visit

Source: Waymark