Are Social Determinants of Health “Special Needs”?
A Conversation with Dr. Cheryl Philips of the SNP Alliance
Dr. Cheryl Phillips is the President and CEO of the Special Needs Plan (SNP) Alliance, a national leadership association for special needs and Medicare-Medicaid plans serving vulnerable adults. A geriatrician by training, she has held key leadership roles at numerous organizations, including Sutter Health, the American Geriatrics Society, the American Medical Directors Association, and Lok-Lifebridge, where she was instrumental in developing the Program for the All-Inclusive Care for the Elderly (PACE). (full bio).
Thanks for chatting with us, Cheryl. Tell us a little bit about the SNP Alliance, who your members are, and what you are advocating for.
The SNP Alliance is an organization of 24 health plans and some additional aligned business members. They’re all focused on specialized managed care for vulnerable, high risk, high cost individuals. Special needs include C-SNP, I-SNP, and then the largest membership of dual-eligibles (D-SNP). We also include MMPs, or demonstration plans. Overall, our members represent over half of all enrolled lives in MMPs.
The SNP Alliance began as an interest group, and has evolved into a broader leadership organization. We’re trying to move our plans forward: what does integration look like? Integration means policy integration, it means aligning benefits, also the regulations and delivery reforms that best meet the needs of our populations.
We’ve long been advocating for more flexibility in benefits, so the idea of some of these new demonstrations, the VBID opportunities, the supplemental benefits, they all come down to how better flexibility in benefit design can allow these specialized health plans to better serve high-risk populations based on their complex set of clinical and non-clinical needs.
Let’s talk about the social determinants of health. There are really two sides to this story: the unmet non-clinical needs of these complex patient populations, and the approaches that health plans and agencies are taking to address them.
I have to start by saying that there is a bigger conversation here, that goes far beyond talking about health plans. These social determinants are deeply rooted in community issues, funding, housing, neighborhoods, poverty, systemic inequality. Insurers are contracted into that, but truly, it’s a bigger conversation just health plans. I’d say that I am a core believer in the importance of SDOH as contributing to health costs and this national health care crisis that people, plans and providers are facing.
Having said all that — I think there is a big opportunity for those plans and organizations who are focused on serving the most vulnerable populations — to give these organizations more flexibility for what they can target and start addressing.
Again, I like to use the concept of integration. Integration at the person level means we’ve got to do a better job covering people. It’s about the medical, social, behavioral, environmental constructs that’s part of these beneficiaries’ day to day lives. Social Determinants doesn’t just mean that any one entity assumes responsibility for all of it, but that they acknowledge there are multiple parts. Our health systems have to think beyond just adding in social services to what they’ve been doing. It starts with looking to understand those other aspects of people’s lives.
At the plan level, integrating Medicare and Medicaid benefits is certainly as good a place to start as any. There’s the operational layer — all of the processes, paperwork, things related to marketing and enrollment — as well as the broader integration of policy, payment, regulation, care delivery.
For example, under D-SNP, plans must be very proactive about these integrations, Long term Services and Supports (LTSS), the behavioral health needs. Integration of all of these layers starts with the person. And very often — I like to use the analogy of a tornado. Individuals don’t think of their lives as chaotic, but when we look at the elements of an individual’s experience from the outside, we see it as a tornado. Integration means stepping in from the outside, being with the person, understanding their full needs, and designing the benefit accordingly. At this stage, even without solving all of those needs, just being aware and coordinating where services can link up would represent real progress.
So, we have a long way to go, but I can say confidently that we’re doing much better than we were a decade ago. We’re at least recognizing where we need to go from here. All the recent signals from the government are a sign of that.
CMS asked for public comment on their proposed rules. Can you talk generally about where things are today, and then maybe go a level deeper and comment about the new supplemental benefits rules that CMS is proposing?
What’s come out of CMS so far is encouraging, but it’s at a very high level, and without a lot of interpretive guidance. We have far more questions than answers, and there aren’t many easy answers: How do supplemental benefits as defined in the MA program overlap with existing Medicaid benefits? Can you go beyond what is allowed at the state level, without duplicating efforts or resources? How should these plans target populations for social needs — what criteria are they supposed to use? What is the sustainability of these new benefits — are they continuous from one year to the next? Can the patients who wind up using a ride or meal benefit in one year count on them to be available the next year?
So there are just a lot of questions where this administration, our policy leaders, and the plans themselves just need to get together and figure out the answers. This is complex stuff, and there’s no quick fix, but I would say that I’m cautiously optimistic with where things are now.
In this context of addressing the SDOH, what does the word “innovation” mean to you?
One thing that I’ve learned about health care organizations — very few want to be the first kid on the block to do something, very few want to go out of the box on new risk models or risk taking. You can see that has started to change. Where there is innovation, I think it’s coming from some of these plans partnering with the entities that are better at taking on risk, using data, getting out beyond the hospital. I think that public/private partnerships is where innovation will blossom. CMS can throw out ideas, the VBID work is a good example — and it’ll be up to the industry to respond.
But still, I’d say those are still rare exceptions. There are some plans that are starting to experiment with technology: Phone-based apps that individuals can elect to participate in, share their SDOH data so that it’s relayed to health plans and providers. In areas like data exchange — everyone is talking about the incredible potential, but inside these organizations, the risk of compromising data integrity, or HIPAA compliance still creates real fear in health plans.
What do you think we need to see more of? What are the major barriers to plans investing effort in going further upstream for prevention and funding non-clinical supports?
Frankly, I still don’t think we have great data exchange between health plans and provider community. Even just at the clinical level, I as the individual — do I have any control over that information? Privacy and integrity questions are still creating the fortress around this wild expansion of data exchange. Perhaps caution is good, but I still think there are a number of communication platforms that can help break down these barriers. I know everyone is talking about this in our circles, especially with things like Telehealth and Behavioral health. We have a dearth of behavioral health providers, but they don’t even know where to begin with payment, let alone tech or data. I think that having telehealth platforms to coordinate care across different silos — clinical, social, behavioral — that is an important area where more progress is needed.
In terms of where technology can help bring us forward, I think the innovation that’s needed is for health plans and providers to be able to communicate in different ways, at the time and place where the individual needs it. The opportunity for tech is to start to move services and alignment of communication and effort to when and where the individual needs it. That’s the essence of person-centered innovation.
Background on the SNP Market, courtesy of the SNP Alliance’s fact sheet:
“As of mid February 2019, CMS had approved 321 MA contracts offering 734 Special Needs Plans (SNPs) with a total enrollment of 2,910,189 beneficiaries. Of these 734 Special Needs Plans, 129 are Chronic or Disabling Condition SNPs serving 351,051; 480 are Dual-Eligible SNPs serving 2,474,821 beneficiaries; and 125 Institutional SNPs are serving 84,317 beneficiaries.”
Related Reading
We’d love to hear your questions, comments, and other feedback!
