For small and independent physician groups navigating value-based care, the transition can feel overwhelming. One strategy, however, is emerging as a powerful catalyst for both better outcomes and stronger financial performance: investing in Social Determinants of Health (SDOH).
Addressing factors like food insecurity, housing instability, and lack of transportation isn’t just a moral imperative—they’re strategic levers for ROI. Recent evidence shows that investing in SDOH delivers meaningful ROI, reduces preventable costs, and elevates the patient experience.
At VBC Transformation Partners, we don’t just support transformation—we equip the people who make it last. Here's how SDOH interventions are redefining ROI for provider organizations across the country—and how your practice can lead the way.
What Are Social Determinants of Health (SDOH) and Why Do They Matter?
SDOH refer to the non-medical factors that influence health outcomes—like where a person lives, what they eat, whether they have safe housing, reliable transportation, or access to social support. These factors account for up to 80% of modifiable health outcomes (Hobson et al., 2025).
According to the CDC, addressing SDOH is essential to achieving health equity and improving overall care quality (Nikpay, Zhang, & Karaca-Mandic, 2024). In a healthcare system where hospital readmissions, emergency department visits, and chronic disease mismanagement cost billions, SDOH are often the hidden drivers of these preventable costs.
Recognizing the importance of these upstream drivers, CMS has rebranded its Health Equity Index as the “Excellent Health Outcomes for All (EHO4All)” reward, effective in 2027. The shift aims to better reflect the goal of ensuring exceptional care for all enrollees (Emerson, 2025).
The EHO4All reward will specifically target groups at higher risk for poor outcomes—such as dual eligible patients, low-income subsidy recipients, and disabled beneficiaries—while also incentivizing systemwide improvement. CMS has also proposed expanding the index to include geographic factors, such as rural or urban residency, to better capture the full spectrum of social risk (CMS, 2025).
SDOH Investments Deliver Measurable ROI
1. Food and Nutrition: From Clinical Burden to Cost Savings
- Average ROI of 85% for food insecurity interventions, with some as high as 287% (Nikpay, Zhang, and Karaca-Mandic, 2024).
- Geisinger’s Fresh Food Farmacy cut per-patient costs by 80%, from $240,000 to $48,000/year by combining food and coaching (Ohanian, 2018)
- Medically tailored meals led to a 52% drop in inpatient admissions and saved $570/month per patient (Commonwealth Fund, 2019)
2. Housing Stability: A Prescription for Better Health
- Housing programs averaged 50% ROI, with top performers exceeding 200% (Nikpay, Zhang, and Karaca-Mandic, 2024)
- A Chicago-based initiative saved $6,307 per patient annually by reducing hospitalizations by 29% (Commonwealth Fund, 2019)
- In San Mateo, CA, housing support saved $6,000 per member per month and delivered a 157% ROI (San Mateo’s Community Care Settings Pilot)
3. Transportation: Reducing Barriers, Improving Access
- Dialysis NEMT programs returned $3,423/month per patient, demonstrating huge savings for chronic care (Commonwealth Fund, 2019).
- Missouri’s HealthTran pilot delivered $7.68 back for every $1 invested while improving rural access to care (Commonwealth Fund, 2019).
These are not side programs. They are cost-saving, outcomes-improving infrastructure investments—built for the future of care. CMS’s EHO4All framework formalizes these strategies, rewarding Medicare Advantage plans that improve outcomes for the most at risk populations (CMS, 2025).
Why It Works: SDOH Interventions Target Root Causes
Rather than chasing downstream medical complications, SDOH initiatives proactively reduce risk, improve engagement, and connect patients to the resources they need to stay well. That reduces high-cost utilization and enhances quality metrics.
At VBC Transformation Partners, we guide practices in identifying the right interventions, structuring sustainable partnerships, and building a roadmap that works with your existing systems and budget.
Practical Wisdom Meets Practical Execution
The financial case is strong, but success requires more than data—it requires direction.
As highlighted in the Health Affairs Forefront article “Rescuing Value-Based Healthcare Through Better Data,” many value-based initiatives have fallen short—not due to lack of intention, but due to fragmented systems, inconsistent data extraction, and a failure to capture the clinical nuance needed to guide real change. Despite the widespread adoption of electronic health records, our inability to extract usable, patient-level data has stalled progress across programs and stifled the very reforms meant to increase value.
At VBC Transformation Partners, we believe the gap isn’t just informational—it’s structural. We understand that closing this particular gap demands more than dashboards or data pipelines. It demands practical wisdom, agile execution, and a partner who can translate insight into action without overwhelming your team.
That’s why we don’t just provide tools—we deliver field-tested strategies, smart analytics, and a step-by-step operational roadmap tailored to your workflows, goals, and team dynamics. Our work is designed for real-world constraints—limited staff capacity, tight budgets, and the urgent need to demonstrate ROI quickly and clearly. We help you move from theory to impact with minimal disruption and maximum clarity.
Because transformation shouldn’t feel like guesswork. It should feel like progress.
Building Your SDOH Strategy: Where to Start
Whether you’re launching your first food pharmacy or evaluating a housing partnership, the ROI is within reach. Here’s how we help you move forward—without the guesswork:
- Demystify ROI with real-world benchmarks and cost-avoidance models
- Pinpoint your ideal pilot with smart segmentation and data analysis
- Structure partnerships with CBOs and navigate shared savings
- Track results using metrics that matter—clinical, operational, and financial Scale smartly with phased rollouts and continuous support
Our transformation partners have seen reduced burnout, stronger Medicare Stars ratings, and millions in cost savings.
Conclusion: The Future of ROI Is Equity-Informed
The ROI of addressing SDOH isn’t theoretical—it’s real, it’s proven, and it’s scalable. With CMS signaling deeper alignment through the EHO4All reward structure, investing in SDOH is no longer optional. It’s strategic.
At VBC Transformation Partners, we don’t just understand the challenges—we’ve lived them. Founded by physicians and grounded in real-world leadership, our solutions are designed to meet providers where they are—and help them move forward with clarity, confidence, and impact.
Ready to Explore Your SDOH ROI?
At VBC Transformation Partners, we’re helping practices align with this next chapter of healthcare transformation. Whether you call it SDOH, health equity, or EHO4All—the goal is the same: excellent outcomes, for every patient, every time.
Let’s turn equity into impact—and impact into returns.
