The Early Innings: Managed Care Markets for Social Determinants of Health (#SDOH) Innovation
A Roundup of Key Opportunities & Challenges in 2019
“Most health plan executives we spoke with told us that when it comes to SDoH interventions, they are still learning. They say that now is the time to experiment with new approaches that can contribute to the SDoH evidence base and hone their business cases.
Some are considering experimenting with technologies such as mobile apps and virtual care, while maintaining one-on-one support programs for high-need and high-risk members. Many are interested in adopting data platforms to share data and evaluate interventions more easily, but say they need to overcome significant technological and operational challenges before they can do so.”
- Addressing SDOH for Medicare and Medicaid Enrollees, by Deloitte
A new paper from Deloitte (Feb 2019) reaffirms what many of our readers of already know: We’re in the early innings of SDOH innovation when it comes to managed care organizations (MCOs) adopting 21st century tools.
The new report offers a roundup of conversations with 14 health plans across four states, in both Medicaid Managed Care and Medicare Advantage markets. Despite the cautious conclusion excerpted above, the report offers some insights into MCO executives’ thinking in several key areas:
- Using multiple modalities to identify social needs: telephonic, online, mail questionnaires are all prevalent today, while in-home assessments often prove more effective than Health Risk Assessments (HRA), especially for high risk members
- New Data, Predictive Analytics, and Machine Learning are piquing health plans’ interests, particularly in the area of augmenting risk scores and detecting unmet social needs
- One on One support is a key fulcrum for enrolling beneficiaries into social care programs. While plans mention social workers, case managers, peer support specialists, or community health workers as key partners, there is no mention of the financial investment being made for these key allies, nor of any type of digital support systems to educate, train, measure, and scale their impact
As a result, many plans still report being unable to measure the effectiveness of these programs. As per the report authors:
“Some say they lack the in-house expertise to run such complex evaluations…plans may not know whether a referral or warm handoff to a CBO resulted in a member receiving a needed service…While several plans told us that some data is shared between the health plan, providers, and CBOs, data-sharing often occurs through manual systems that are resource-intensive and inefficient.”
The paper does mention one example of a plan adopting a “multidirectional data platform” to meet these needs, and points to the North Carolina’s NCCare360 as well as the broader spread of value-based contracting as examples of how state-level policy and broader market reforms will help drive health plan innovation around SDOH.
While federal level Medicare Advantage reforms will help introduce sweeping new flexibility for MA plans to address SDOH through existing reimbursement channels, Medicaid represents a wildly different type of market. As a state level program, the variability from agency to agency make reimbursement strategy more difficult to gauge.
A Closer Look: Medicaid Managed Care
A recent report from the Institute for Medicaid Innovation (Jan 2019) offers a lengthy deep-dive on the intersection between state level regulations, reimbursement mechanisms, and investment opportunities for specific populations.
Below, we highlight three increasingly common strategies that health plans around the country are taking, drawn from this new report as well as other recent topic papers from around the industry.
1. Develop a Strategy around “Z-Codes”
While ICD-10 introduced new ‘Z-codes’ to document social dimensions of patient’s health back in 2015, it’s only recently that these new elements are making their way into routine workflow. This has been driven both by changes in policy and broader industry recognition of the importance of SDOH data capture.
The challenges that Z-Codes face are well-documented: new codes requires new training, and without responsive care planning, payment, or referral infrastructure in place, the data on their own don’t help patients, even if staff are trained in their use.
A case study by CHCS includes the example of how a health system in Montana created a crosswalk to tie these new codes to specific SDOH screenings to customize the care planning process. For this particular clinic, this approach including a home-grown approach to referring social services. As the above chart summarizes, the applications span hunger, financial stress, education, and more.
A more comprehensive table of Z-Codes is also available here (page 10.)
2. Incorporate Validated Screening Assessments
While coding SDOH into the healthIT enterprise is critical for broader efforts to coordinate care, improve documentation, and produce more accurate risk adjustment, on their own these new codes don’t capture data. For that, MCOs need to incorporate validated screening tools to assess a beneficiary population for unmet social needs.
The report includes an example of from Upper Peninsula Health Plan, a Medicaid MCO that has set up a comprehensive, community-wide SDOH screening and referral network called the Connected Communities for Health (CC4H). CC4H is an award winning program that leverages a call center, volunteer efforts, and a network of community based organizations (CBO) across “adult education, childcare, commodities (e.g. household goods/furniture, baby supplies, clothing), employment, finance, food, housing, legal services, transportation, and utility assistance.”
3. Develop Effective Cross-Sector Partnerships for Social Referrals
If screening patients for their social needs is a first step, then facilitating referrals out to non-medical partners in the community represents the next step. Unfortunately, this proves quite challenging in the field.
For starters, health insurers have shown a poor ability to maintain accurate directories of medical doctors, a credentialed and organized class of caregiver with whom they do business regularly; the hodgepodge of CBO, social workers and other agencies (housing, child services, NEMT brokers, and others) that comprise the social services space pose a far more daunting challenge.
Moreover, building these networks in a sustainable fashion is even more of a challenge. As the IMI report puts it (page 8)
“more information is needed on the value of social services rendered to better quantify the cost and evaluate the impact of social intervention efforts. To facilitate the valuation of services, there is a need to establish units of service related to some quantity of social intervention and billing codes to support payment between health plans and community-based organizations and to establish a total cost of care. The absence of this type of infrastructure poses challenges to Medicaid MCOs with implementing incentives or value-based purchasing strategies with partners.”
For a closer look at the dynamics of partnership between Medicaid MCOs and CBOs, we recommend this fantastic deep dive report by BCBS Foundation of Massachusetts. It’s a unique report looks at the ecosystem of SDOH Innovation and the role that CBO are playing (and not playing), from the underrepresented perspective of these community organizations themselves.
As this report makes clear, CBO remain an undervalued partner when it comes to crafting policy and designing reimbursement models to address the SDOH. Below are some select excerpts from CBO leaders that illustrate the extent of the challenge that MCOs will face in bridging gaps in trust, data, and dollars — key requisites for healthy partnerships.
- “One person mentioned that the CBO sector “operates in a mind-set of poverty” compared with the relative wealth of health care organizations.”
- “Honestly, my fear right now, we are so late as a community. Like, quality metrics at MassHealth are being finalized right now. We were not invited to the party.”
- “My concern is that it’s a money grab … That there won’t be dollars for the services people on the ground need to have positive lived experiences … The medical industry will absorb the resources.”
- “There is just no way that they can be a hospital but also then become a food bank. It’s an incredibly huge operation, with food logistics and acquisition.”
As the managed care markets for SDOH innovation continue to evolve based on regulatory dynamics, technology adoption, and a growing evidence base of ROI, we expect broadening industry consensus that upstream prevention represents the long tail of value-based care — and the future of healthcare reform.
