Medicare health plans have increasing authority to grapple with the social determinants of health, and more are pursuing such initiatives.
Medicare Advantage (MA) plans commonly implement risk-based contracts with providers in their networks for the total cost of enrollees’ care. And plans have seen a growing number of contracted providers add programs aimed at addressing the social determinants of health (SDOH), said a leading advocate for MA plans.
Home assessments and transportation to medical appointments were among the SDOH initiatives highlighted by Allyson Schwartz, president and CEO of the Better Medicare Alliance (BMA), a group that includes MA plans covering 400,000 enrollees.
Although BMA has no comprehensive data, Schwartz said providers have found net savings from such initiatives.
“They are seeing some return, the ones that have been doing it already,” Schwartz said. “They wouldn’t continue to do if it wasn’t making a difference in terms of keeping people out of the ER and keeping people out of the hospital.”
In a report on MA benefits that have been newly added in 2019, Milliman concluded half are in-home support services, such as personal care aides to assist individuals with disabilities or major medical conditions. Nearly one-third of plans extending the new benefits will offer home-based palliative care “to diminish symptoms of terminally ill members with a life expectancy of greater than six months not covered by Medicare,” according to the report.
Broader SDOH options expected in 2020
Schwartz said she expects MA plans’ SDOH programs to greatly increase beyond the limited offerings of 2019.
Starting in 2019, the Centers for Medicare & Medicaid Services (CMS) allowed MA plans to offer supplemental benefits, such as adult day care services or in-home and caregiver support services, and cost-sharing benefits for enrollees with certain conditions. CMS garnered a lot of attention when it tweaked its rules for 2019 to:
- Allow home-based palliative care, nonskilled in-home support and services, and nonopioid pain management
- Expand permissible benefits, such as by covering temporary home modifications and bathroom safety devices
However, CMS noted only 270 MA plans — out of 3,700 — opted to provide enrollees with the new types of supplemental benefits in 2019.
Schwartz blamed the limited embrace of such initiatives on the short time frame between finalization of the rules and CMS’s rate-filing deadline.
“But we’re seeing more and more interest,” Schwartz said, referring to the 2020 coverage year.
For 2020, CMS rules expanded permissible SDOH expenditures by plans for patients with chronic conditions. Plans will be able to:
- Offer non-healthcare-related benefits that can improve or maintain health or overall function
- Expand meal delivery
- Provide transportation for nonmedical needs like grocery shopping
- Offer home environment services like air conditioning installation or repair
Plan bids for 2020 were due June 3, and Schwartz said she does not know details of what each plan is proposing to offer next year. But as an example of the growing interest, she cited the high-profile partnership of Lyft with several insurance plans to offer nonemergency medical transportation for MA enrollees.
“We expect that there will some additional benefits offered,” Schwartz said.
Jamo Rubin, founder and CEO of TAVHealth, agreed that the larger financial incentives for insurers will lead to expanded SDOH program offerings in 2020.
“People are beginning to figure this out, and it is all because the incentive structures are changing,” Rubin said in an interview.
Some may not be ready to pursue SDOH initiatives
New SDOH programs most likely will appear first among longer-established plans and among providers that have tried such initiatives as part of other payment programs, Rubin said. He cited the experiences of plans and providers that have taken part in emerging CMS models and alternative payment models in a growing number of Medicaid programs.
“Those that have been through more cycles — look at the state Medicaid [requests for proposals] — are getting more and more specific about social determinants,” Rubin said. “The new folks don’t really know; social determinants is a word like population health [and they say], ‘I don’t really know the answer.’”