Challenges and Opportunities Seen in Social Determinants

For a variety of reasons, relatively few Medicare Advantage plans will offer newly permissible supplemental benefits in 2019, says one industry leader.

Oct. 10—Providers and insurers are seeing a range of obstacles and new opportunities in efforts to better address the most powerful factors affecting patient health.

A growing body of evidence has established that social determinants of health (SDOH)—such as lifestyle choices, income levels, and life necessities—are responsible for about 60 percent of health outcomes. In comparison, the quality of health care is responsible for only about 20 percent of health outcomes, said Jason Barker, market president for ChenMed, an integrated primary care practice that provides low-income care for Medicare Advantage (MA) plans.

At an Oct. 10 event in Washington, D.C., representatives of providers and health plans said they were increasingly grappling with ways to address SDOH among patients, enrollees, and local communities.

For instance, Cityblock Health in Brooklyn recently launched an initiative that combines primary health care, a nonclinical team hired from the community to connect patients with local resources, and a “community hub” to provide both a gathering place and a healthcare setting.

The provider group accepts risk from insurers to provide care for the patient population under a capitated funding arrangement. That payment model allows for more investment in nonmedical needs and for the provider group to partner with community organizations, said Melanie Bella, MBA, chief of new business and policy at Cityblock.

Insurers “need help and have gaps they cannot fill,” Bella said about Cityblock’s role in addressing SDOH.

Challenges Seen

A growing body of data shows that partnerships with community-based organizations that provide services to address SDOH can reduce healthcare costs, such as those stemming from emergency department use and hospital readmissions, said Lucy Theilheimer, chief strategy and impact officer for Meals on Wheels.

“We need to improve connections between providers and community organizations,” Theilheimer said.

Availability of funding is the leading challenge that health plans and providers have encountered in their efforts to address SDOH before affected patients need costly care.

For instance, local community groups that provide needed services—like food, housing, and transportation—often are underfunded and spend a lot of time looking for temporary grants.

“It makes it harder to have a stable partner who can really deliver what they want to deliver, because if they are constantly distracted with having to write the next grant, find the next source of funding, it’s very hard for them to be able to focus on ultimately what their product or service is,” Barker said in an interview. “It gets in the way of being able to have a stable, functional long-term relationship.”

Many health plans and providers end up creating their own initiatives that recreate the programs of local community groups, he said. For instance, ChenMed’s medical centers have had to buy their own buses, as well as using commercial car services.

“And it’s largely because we can’t rely on those community-based transportation services because they are just unreliable,” Barker said.

Advocates also were worried that a proposed rule issued in July by the Centers for Medicare & Medicaid Services (CMS) could undermine states’ efforts to address SDOH among Medicaid enrollees. The rule would reverse an option that CMS has given state Medicaid programs since 2014 to divert provider payments to other entities.

CMS officials said the change was needed to preserve provider payments, but Theilheimer said it runs counter to a growing understanding about the health benefits of addressing SDOH.

New Options

One newer alternative will allow MA plans to offer supplemental benefits, such as adult day care services or in-home and caregiver support services, and cost-sharing benefits for enrollees with certain conditions.

“We have long said there are opportunities to look at the services the person needs,” said Cheryl Phillips, MD, president and CEO of the Special Needs Plan Alliance.

However, a CMS release issued in September noted only 270 MA plans—out of 3,700—will provide enrollees with the new types of supplemental benefits in 2019.

Part of the reason is that plans did not have time to adjust their 2019 offerings to include those options, Barker said. Another challenge was a lack of additional funding for those optional benefits, so plans need to figure out how to afford them.

“A lot of MA plans may decide, based on what is going on in their market, ‘I could compete better on a richer Part D benefit or a richer Part B benefit; I don’t necessarily know that I’m going to invest in these other services,’” Barker said.

That reluctance could be especially strong among plans that operate contracts that shift much of the risk to providers—which would leave the plans to focus on appealing to new enrollees, who often value a richer Part D benefit, Barker said.

Nick Uehlecke, staff member for the House Health Subcommittee, said he hoped MA plans utilize another new option to provide telehealth services and to collect data on whether such services improve outcomes and lower costs. Such data is needed to overcome congressional scorekeeping that traditionally views telehealth as a net cost-driver and effectively blocks legislation to expand Medicare payment for telehealth benefits.

Another way CMS could encourage a focus on SDOH is through new payment models that are under construction, said Edwin Walker, deputy assistant secretary for aging with the U.S. Department of Health and Human Services. Such models will aim to connect community-based services to home-based care by focusing on enrollees, caregivers, and social service entities as complements to healthcare providers.

In a related push, Sens. Bob Casey Jr. (D-Pa.) and John Thune (R-S.D.) recently wrote CMS to urge that the agency also create value-based payment models that address the opioid epidemic, said Stacy Sanders, deputy staff director of Senate Special Committee on Aging.

And coming in 2019 will be a push to reauthorize the Older Americans Act—but with more funding. That legislation was widely credited with funding partnerships—with strong local flexibility—that successfully address SDOH.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare