As the healthcare landscape continues to evolve, the shift to value-based payments is reframing the paradigm for lowering costs while increasing care quality. With considerable evidence that interventions aimed at social determinants of health can positively influence health outcomes and costs, the discourse is changing among providers and policy influencers to look beyond disease and clinical conditions and address the environmental factors that impact our healthcare system.
Managed care organizations (MCOs) can play a pivotal role in this shifting model by focusing resources to partner with providers and the community—addressing social determinants of health. The benefits of these efforts extend beyond reduced care costs to include member retention and improved provider satisfaction.
It’s Time to Address Social Determinants of Health
States continue to protect Medicaid budgets with increased growth in managed Medicaid. Additionally, CMS and health plans are increasingly shifting provider contracts to value-based structures such as accountable care organizations or Merit-Based Incentive Payment Systems and/or Advanced Alternate Payment Models as outlined in the Medicare Access & CHIP Reauthorization Act of 2015. These new contracts exacerbate providers’ struggles as they relate to environmental factors affecting their patients. In fact, 80%
of physicians feel ill equipped to address patients’ social needs despite understanding that they can be just as critical as medical needs. By proactively working with contracted provider groups, MCOs can drive meaningful improvements in both healthcare costs and member care.
When MCOs extend their support, members respond with increased loyalty, translating to greater retention and less member churn. In fact, the Health Affairs
blog notes that 69% of patients are more likely to recommend a healthcare organization that assists with access to basic resources. A study by Altegra Health released data showing that Medicare Advantage plans increase average length membership by 21% when members are screened and receive support for social and community-based resources.
Proactively Addressing—and Impacting—Social Determinants of Health
Organizations lacking a sound plan to address social determinants of health or those who wish to improve their programs should consider the following steps and strategies:
Start small. The most fundamental step for plans just getting started is to broaden their notion of case management to consider factors outside of traditional healthcare needs. If a plan has yet to begin assessing and stratifying members based on social determinants of health, starting small is key. For instance, begin by targeting a specific social need or demographic such as those with lowest income or most frequent emergency department visits.
Analyze the value and meaningful impact of existing programs. Plans with social determinants of health programs currently in place should assess performance based on value to the member’s need and location. For example, geographically inconvenient programs or those with overly restrictive requirements are less valuable than those directly impacting daily living, such as utility assistance and food support. Plans can create a “value score” for programs to assure the best value for members, identifying key areas including: health and healthcare, economic stability, education, social and community content. Then, plans can tie attributes to those programs, considering specifics such as the program’s essentialness, benefit frequency, accessibility and capacity limits.
Create a community program strategy. Housing and job assistance are often the most significant resource needs, yet they’re often the most daunting to address. To avoid getting “stuck,” build a bank of community resources for the next “tier” of common needs, including food, utilities, transportation, medication assistance and telephonic communication.
Implement a sophisticated program and member tracking tool. Programs and their supporting requirements change often. Using a software tool for program maintenance assures varying roles within the organization have access to the same program details. Find a software tool to effectively track member programs, including application processing, and plan to integrate that data into care management systems. Most importantly, be sure to partner with a software vendor capable of effectively maintaining and enhancing your program database.
Integrate a screening tool with community program and member tracking tool. Expand care management screening to include and score members based on social needs. Because members’ needs are often unique, adopting a technology solution capable of stratifying, standardizing and facilitating support will help programs be more effective and efficient. For instance, a tool that matches members with appropriate resources or services can have a tremendous impact, not only by meeting member needs, but also by streamlining the process to optimize the efforts of care managers and social workers.
Partner with provider groups. Engage provider relations to identify those struggling to address their patient’s social needs. Consider extending the aforementioned screening and community program software tools and encourage collaboration by exchanging information related to member needs and programs accessed.
Enhance member communication. Whether using live or automated calls, text messages and/or a combination of various methods, programs should not only increase benefit awareness, but provide direction on proactively seeking assistance when they need it. A plan should make available services known and have a visible presence in its community. Doing so will keep members engaged by meeting them where they are and building trust—something many individuals typically lack when it comes to their healthcare plans.
Actively participate in the creation of health policy. Together, healthcare entities can influence health policy that creates meaningful incentives to unify interventions for social determinants with clinical care. Whether Medicare, Medicaid, or private accountable care organizations, effective change can produce long-term cost reductions and improvements in care that benefit the entire industry.
By leveraging technology to identify, stratify and facilitate programs that address not only the medical but also the social needs of its members, managed care plans can serve as an invaluable resource. After all, what’s more meaningful than preserving member retention and loyalty while reducing costs and producing better overall health outcomes?
Producing Favorable Outcomes