Social Determinants of Health

Moving to the Next Generation of SDOH Initiatives

May 6, 2019 3:13 pm

March 14—Efforts to address social factors that affect health are moving from the experimental phase to the operational phase in Medicaid, according to a former federal leader of the program.

Medicaid managed care plans and the Medicaid programs that oversee them are moving from launching pilot efforts that address the social determinants of health (SDOH) to broadly operationalizing such initiatives, said Cindy Mann, JD, a partner with Manatt, Phelps & Phillips and former head of the Medicaid office at the Centers for Medicare & Medicaid Services (CMS).

“There’s been a fair amount of experimentation—a lot led by health plans themselves,” Mann said at the annual policy event of America’s Health Insurance Plans. “States and plans—and to some degree health systems—are now thinking about that next generation. How do you bring it to scale, how do you systematize it, how do you think about a sustainable financial arrangement, and also how do you test it—what interventions work, what interventions don’t work.” 

For instance, North Carolina is transitioning its Medicaid program from fee for service to a managed care system. As part of that, the state has pushed to incorporate SDOH in “every aspect of the delivery system,” Mann said. Specifically, care management requirements were instituted as part of a value-based purchasing push.

Additionally four regional pilots were established through a $650 million waiver approved in the fall by the Trump administration. With the waiver authority, North Carolina will implement a program to address SDOH for high-risk, high-cost beneficiaries by emphasizing managed care and substance-use disorder services. The waiver will pay for services that otherwise would not be eligible for Medicaid funding.

Sara Rosenbaum, JD, professor of health law and policy at George Washington University, said she was heartened that Medicaid programs and insurers are increasing their efforts to address SDOH. However, she warned that such efforts cannot cannibalize existing Medicaid budgets, but instead need new funding.

“It’s not sustainable to decide you’re just going to divert a lot of Medicaid money into the effort,” Rosenbaum said.

Dean Rosen, JD, partner at Mehlman Castagnetti Rosen & Thomas, praised Medicaid managed care plan efforts, as well as Trump administration support of those efforts in areas like food insecurity. He highlighted some Medicaid insurers’ use of contractors to provide home-delivered meals for their chronically ill patients and transportation to physician appointments.

Health Plan Efforts

Christopher Palmieri, president and CEO of Commonwealth Care Alliance, which covers Medicare and Medicaid dual-eligible enrollees in Massachusetts, said the organization has long tried to address SDOH.

For instance, in 2018 it coordinated more than 600,000 one-way trips for enrollees to medical appointments and provided home safety modifications, air purification systems, and air conditioners.

“All of these things are focused on keeping a human viable in the community, not in places we’ve been trying to avoid as a healthcare system and society, like the emergency room or acute care hospital setting,” Palmieri said.

Each enrollee is personally assigned to one of Commonwealth Care Alliance’s 1,200 employees and given the employee’s name and number to contact with any issues. The health plan has found that on average, costs are reduced by 26 percent for every 50 contacts between staff and enrollees—often due to avoided emergency department use.

The health plan’s data analysis has found “the more we touch a consumer the better off their life gets, the better their healthcare costs improve,” Palmieri said.

Such touch points range from conversations in enrollees’ living rooms to communication in the physician’s office or over the phone.

The ability to establish high levels of individual engagement with patients who historically were noncompliant was credited to the individual care plans that the patients help create—usually in an appointment lasting no more than 90 minutes—to address their specific concerns.

“Once we can start to solve for those problems, we can have a dramatic impact in all of those touch points,” Palmieri said. “This is really the secret to our success.”

Sustainability Efforts

As an insurer, Commonwealth Care Alliance has had to find savings because the cost of treating underlying health conditions and providing personal care services exceeded the premiums they were paid. To address that, over the last two years the company has sought to add home-based technology to reduce some human labor costs.

Palmieri warned insurers looking to impact SDOH not to delegate the issue to their primary care providers because thoughtfully addressing it requires the full focus of the health plan.

Chris Wing, CEO of SCAN Health Plan, noted that surveys are finding that large shares of primary physicians are burned out.

“We can’t put anything else on their plate,” Wing said.

Health plans need to use their data to figure out the challenges for their enrollees and then intervene directly with resources that can help address SDOH, Wing said.

Cain Hayes, president and CEO of Gateway Health, said his company 15 years ago created a database for enrollees in which it collected data on resources offered by 3,000 community organizations. The plan gave its providers access to the database as a source of practical tools that could help address SDOH for their patients.


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