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Clinical Interventions Addressing Nonmedical Health Determinants in Medicaid Managed Care
Laura M. Gottlieb, MD, MPH; Kim Garcia, MPH; Holly Wing, MA; and Rishi Manchanda, MD, MPH
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Clinical Interventions Addressing Nonmedical Health Determinants in Medicaid Managed Care

Laura M. Gottlieb, MD, MPH; Kim Garcia, MPH; Holly Wing, MA; and Rishi Manchanda, MD, MPH
This review examines the breadth of published work on interventions addressing nonmedical determinants of health that are supported by Medicaid managed care organizations.

ABSTRACT

Objectives: We aimed to examine how interventions addressing social determinants of health (SDH) have been adopted in the context of Medicaid managed care organizations (MMCOs), which serve a large proportion of patients with social and economic barriers to good health.

Study Design: We designed a systematic literature review to examine how SDH interventions have been adopted in MMCOs.

Methods: The review included published articles from PubMed, Scopus, and Business Source databases, as well as review articles published in the gray literature and articles recommended by the study’s National Advisory Committee to identify interventions describing how MMCOs have invested in interventions that address patients’ SDH. To be included in the review, an article had to describe an intervention that was based in the United States, be supported financially by an MMCO, focus on at least 1 SDH, and be integrated into clinical care delivery.

Results: Twenty-five programs were identified in either commercial Medicaid or Medicaid-only MCOs that involved interventions integrated into clinical care and related to SDH. Interventions varied widely in terms of target populations and target SDH, and rarely included rigorous evaluations. The majority of programs described “case management services” that did not clearly distinguish between the delivery of medical and social interventions.

Conclusions: Despite a growing interest in clinical interventions that address SDH, little information is available in the published literature about the extent to which these interventions have been adopted by MMCOs, where they are likely to have early traction based both on capitated funding structures and the low-income populations served.

Am J Manag Care. 2016;22(5):370-376

Take-Away Points
 
Medicaid managed care organizations (MMCOs) have increasing incentives to support interventions addressing the social needs of the low-income patients they serve. 
  • MMCO investments are focused on social needs interventions for high healthcare utilizers and on members anticipated to become high utilizers based on specific health conditions like hypertension and diabetes. 
  • Few studies were identified to indicate that MMCOs are making organizational commitments to social screening or social interventions. 
  • More information is needed on MMCOs’ organizational decision making around nonmedical health interventions, the funding streams supporting these interventions, and their impacts on health outcomes and health services use.
The World Health Organization’s (WHO) Commission on the Social Determinants of Health has defined social determinants of health (SDH) as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.”1 These conditions include social, economic, and environmental factors, such as income, education, housing, employment, transportation, and the physical layout of neighborhoods.

There is increasing evidence that SDH play a major role in the onset and progression of disease. Addressing SDH may help achieve the healthcare “Triple Aim”—improved healthcare quality for individuals and populations, and decreased healthcare costs.2 Despite this, much of the field of social epidemiology—including that related to healthcare disparities—focuses on documenting the effects of SDH rather than on ways to change or intervene on exposures.3

Existing social interventions integrated into clinical settings—which range from interventions offering housing to homeless patients to on-site food pantries and legal services clinics—can expand the traditional bounds of healthcare to address “upstream” determinants of health, including social, behavioral, and environmental conditions.4-6 Although the field of interventions related to nonmedical health determinants is growing in clinical settings around the country,7 little is known about the operational and design characteristics that define them—particularly in the context of differing payer and provider environments. Understanding how SDH interventions are designed, implemented, funded, and scaled within distinct payer environments is key to translating the growing interest around the role and replication of SDH interventions in healthcare settings into a substantive, actionable strategy.  

Based on distinct membership characteristics and financial incentives defining Medicaid managed care organizations (MMCOs), these payers may be particularly well-suited to support integrated SDH approaches.8 The populations served by MMCOs are disproportionately affected by poverty and associated material deprivation, including food and housing insecurity, poor habitability, unsafe drinking water, social exclusion, low education levels, and unemployment. These conditions are known to reduce opportunities, limit choices, and threaten health.9 Additionally, over the last 15 years, there has been a nationwide increase in patients enrolled in MMCOs,10 which already enroll about half of all Medicaid beneficiaries.11 This combination of population needs and the shift toward risk-based care together encourage upstream intervention and prevention as one potential way to limit costly healthcare utilization.

Despite the apparent alignment of these structural characteristics with low-income members’ unmet social needs, there are multiple challenges limiting MMCOs from expanding social services.12 New prevention services are not easily incorporated into MMCO-state capitation agreements, so MMCOs have to cover any additional benefits out of administrative or community benefit dollars. Coding practices and other administrative requirements for MMCOs can also make it difficult to adopt new prevention services. Furthermore, any financial return related to social service investments may take many years to realize, which can decrease the financial feasibility of adoption. Finally, MMCO care delivery models, financing contracts, and organizational structures (which may span several states) can make community collaborations and public partnerships—often critical to a comprehensive approach to social service delivery—more challenging.

A Systematic Review of Clinical Interventions Addressing Nonmedical Health Determinants

Reviews completed to-date on clinical SDH interventions have offered an important glimpse into the range of potential interventions and funding mechanisms in this emerging field, but have not answered key questions about the implementation of these interventions, their financial drivers, and other characteristics specific to the context of MMCOs.7,13,14 We conducted a systematic review to identify published literature on clinical SDH interventions supported by MMCOs, the design and integration of these programs into healthcare delivery systems, and the determinants addressed and the target populations served by these programs. Our aim was to inform health policy decision makers around incentivizing these programs for broader dissemination.

Based on previous research in the area of clinical SDH interventions, models of organizational readiness for change,15 and an assessment of existing MMCO structural incentives and barriers to incorporating these interventions into routine activities, we developed a theoretical model outlining the range of ways that MMCOs might engage in activities related to SDH (Figure 1). We hypothesized that most MMCOs would be making low-SDH investments, given the relatively recent increase in SDH research.

METHODS
We conducted a literature review examining how commercial and Medicaid-only MMCOs invest in interventions that address SDH for their patients or their network clinics’ patients. To be included in our review, an intervention or program had to meet our inclusion criteria: a) based in the United States, b) financially supported by an MMCO, c) address at least 1 social determinant of health (housing, employment, food, education, safety, legal services, or transportation), and d) be integrated into the healthcare services delivery system. The definition of SDH varies in different contexts, so we focused our search on SDH not typically addressed within the current healthcare delivery system. As a result, we excluded papers describing interventions related to health behaviors, including behaviors like tobacco use and physical activity. We also excluded papers describing interventions exclusively related to healthcare access. Clinical integration meant that a patient’s social need was identified within the clinical setting and then either referred to an external intervention program or to a social intervention conducted in the clinical setting.

We developed an electronic search strategy to scan for references in the following databases: PubMed, Scopus, and Business Source. We limited our search to publications dated 2000 to 2014 and we combined search terms using “AND” to capture at least 1 term from each of 3 major categories: SDH, healthcare settings, and intervention studies (see eAppendix for more detail [eAppendices available at www.ajmc.com]). Funding source was added as an element of the detailed data extraction process on references meeting other review criteria. References were also collected from national experts in the field, including the study’s national advisory group.

Our review methods included a hierarchical exclusion process. Titles and abstracts of references collected from the electronic search strategy and the national study advisory group were assessed initially based on whether or not they described an SDH program or other intervention. Where the title and abstract were insufficient to deduce if they referred to an intervention, the full-text article was reviewed. Those references that referred to SDH but did not describe an intervention were excluded; in other words, articles were excluded if they only described theories of SDH or studies on risk factors and disparities without describing any specific intervention or program addressing those risk factors or disparities.

Remaining references were excluded if they did not describe an intervention or program addressing at least 1 SDH. For example, references were excluded if interventions or programs focused exclusively on medical care and services, such as treatments, immunizations, or health behaviors; described quality improvement interventions without an SDH component, such as guidelines intended to improve clinical care coordination that did not address social needs; or exclusively described healthcare access interventions or outreach programs, such as mobile health services or Medicaid enrollment programs.

References describing an intervention addressing SDH underwent review of the full-text article to determine the degree of clinical integration and financial support from an MMCO. Those interventions or programs without any description of clinical integration or MMCO support were excluded from the final data set. For instance, interventions and programs that were community-based and had no integration with clinic-related work flows related to screening, intervention, referral, or tracking, were excluded. Two investigators reviewed each article included to determine if it met all inclusion criteria. A third investigator reviewed any articles where the reviewing investigators were in disagreement; in these cases, final decisions were made about inclusion after discussion between all reviewers. Interventions described in more than 1 reference were only counted once.

For those interventions and programs meeting inclusion criteria, we collected a detailed set of program data, including intervention name, organization, name/state of MMCO, HHS region, clinic setting, program start date, description of the intervention or program, target population, target SDH, level of intervention/prevention (primary, secondary, tertiary), model of intervention (social and/or medical approaches), level of clinical integration (extent to which clinical providers identify/address social need), study citation, study design, study findings, and an assessment of evidence quality based on the Community Guide to Preventive Services evidence rating guide (high, medium, low quality).

Findings

The electronic search strategy yielded 3975 unique references from PubMed, Scopus, and Business Source (Figure 2). References from our national experts included, but were not limited to, reports from the Association for Community Affiliated Health Plans, Alliance of Community Health Plans, Medicaid Health Plans of America, Manatt Health Solutions, and the Institute for Alternative Futures.

A total of 111 articles were identified that included SDH interventions. These 111 articles were screened to determine whether they described interventions integrated into healthcare delivery systems and whether they were funded by MMCOs. Although many described serving Medicaid populations, only 13 articles described Medicaid managed care–supported interventions addressing SDH integrated within a clinical setting. The final data set included 25 interventions and programs described within those 13 articles.12,16-27 Seven references described 1 primary SDH-focused intervention or program12,16-18,21,22,26 and 6 references described more than 1 intervention.19,20,23-25,27 

Targeted Populations, Targeted Social Determinants, and Intervention Models

 
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