Abstract
The disturbing declines in life expectancy in some populations within the United States over recent years have highlighted the importance of social, behavioral, and environmental factors – factors encompassed in the term social determinants of health (SDOH) – in promoting health and reducing premature mortality and preventable health care utilization. Healthy People 2020 defines SDOH as the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” 1 Some SDOH – such as income, social status, race/ethnicity – are not readily modifiable. However, there is growing evidence that health system-level interventions aimed at addressing other key SDOH (eg, food insecurity, housing instability, social support, low health literacy) can improve health outcomes and reduce costs. 2 Thus, many major US medical societies and associations are calling for actions that systematically integrate screening for and initiatives to address SDOH for their patients. 3
Health plans are especially well positioned to effectively address SDOH because the vast majority of health care spending in the United States flows through them. Health plans bear financial risk for patients; thus, targeting investments to address social needs that contribute to high beneficiary health care costs, including acute care utilization and poor health outcomes, can make financial sense. Value-based provider payment frameworks provide new opportunities for health plans to strengthen alignment of incentives for providers with addressing unmet social risk factors.
Moreover, as state Medicaid and federal Medicare policies increase funding for integration of medical and nonmedical services, health plans will need to develop effective approaches to support such integration. The launch of the Center for Medicare and Medicaid Innovation Accountable Health Community Model in 31 communities nationwide signaled the interest of the largest payer, Medicare, in developing novel strategies for payers to encourage health systems to address SDOH. In addition, more than half of states now require Medicaid Managed Care Organizations (MMCOs) to have a plan for how they will address SDOH. And in states such as Colorado, Washington, Minnesota, Michigan, and Oregon, among other states, Medicaid Accountable Care Organizations are now successfully addressing both social and health needs by developing measures to assess SDOH and linking clinical and nonclinical service delivery. 4
In light of these new opportunities, we briefly outline 4 recommended actions for health plans to improve beneficiaries' health by addressing their SDOH.
Recommendation 1: Invest in Systematic and Standardized SDOH Data Collection and Analytics to Catalyze Greater Effectiveness in Program Design and Implementation
An essential first step in addressing SDOH in the health care environment is to systematically screen for and identify unmet social needs. Unlike individual health systems, health plans already gather comprehensive and detailed claims data across health care providers and settings to be able to identify high-cost, high-utilizing patients who are likely to have unmet social needs such as social isolation. This could include targeted screening for SDOH among these most vulnerable patients such as those in the top 20% of health care costs and with high numbers of emergency department (ED) visits, ambulatory care-sensitive hospitalizations, or behavioral health visits. Other approaches include leveraging existing secondary data sources to develop risk profiles. Such risk stratification is the approach that Massachusetts Medicaid is undertaking through the use of existing data sets that can profile socioeconomic status. 5 Broad-based screening of all plan members could be done efficiently if individual-level data on SDOH were collected as part of plan enrollment or annual renewal of benefits.
Recommendation 2: Develop, Implement, Evaluate, and Disseminate Evidence-Based Pilot Community Interventions with Predefined Scaling Strategies
By rigorously evaluating pilot demonstration projects, health plans can build a strong evidence base of innovative health plan approaches to address beneficiaries' SDOH. In the short term, health plans may want to target specific communities with a high concentration of particularly high-need, high-cost beneficiaries to develop and rigorously evaluate a comprehensive approach. After investigating the priority SDOH needs for at-risk patients in these communities, targeted interventions could be developed. One example of a rigorously evaluated program covered transportation expenses or provided transportation to patients with poor access to transportation. Investigators calculated that if even 1% of medical trips paid for resulted in one avoided ED visit, the return would be $11.08 for each dollar invested in this program. 6 In another example, in Louisiana, the state Medicaid agency in conjunction with the Louisiana Department of Health have joined together to create the Permanent Supportive Housing (PSH) program that provides permanent, subsidized housing with a range of supportive programs for people with disabilities. 7
Health plans also should leverage philanthropic and community benefit programs to test and evaluate approaches to improve SDOH. Initiatives could target grant programs for community and health care system partners to test approaches to address specific SDOH needs or specific populations, to establish local intersectoral partnerships, and to strengthen the social services partner infrastructure. Statewide health plans such as the Hawaii Medical Service Association, for example, have developed grant programs to support innovative projects from participating health systems and local community partners, many of which are seeking to better address SDOH. 8 Through support for demonstration projects, health plans can generate a more extensive evidence base on cost-effective ways to address SDOH. These can become playbooks for health plans and providers to improve population health and support the spread and scale of successful models.
Importantly, health plans also should share lessons learned from unsuccessful pilots to refine and accelerate work in the field. There are a plethora of promising yet still untested approaches to explicitly target SDOH. Thus, as health plans and systems experiment with different strategies, it will be important that they delineate and share information on program components, implementation processes, and outcomes. Toward this end, the Blue Cross Blue Shield Institute, launched in March 2018, serves as an outstanding model of a health plan subsidiary dedicated exclusively to generating data on and evaluating innovative approaches to address SDOH. One example of an initiative they are implementing and rigorously evaluating is a partnership with Lyft, the ridesharing company, to address transportation-based SDOH in neighborhoods with poor public transit access and low rates of vehicle ownership. 9
Recommendation 3: Align with Value-Based Payment Transformation and Sponsor Programs to Improve Alignment Across Resources
Health plans have been leaders in promoting value-based care. Likewise, they can play a leading role in promoting alternative payment models in which financial incentives encourage and support health care providers to address health care-related social needs. This could be done by incorporating individual-level measures of SDOH in risk adjustment models, by focusing on rewarding improvement and not just attainment of high performance, or by introducing quality metrics in payment transformation that focus specifically on reducing disparities.
Providing targeted resources to physician organizations to help address social determinants in the communities of their patients would aid this effort. Health plans can impact care models that address SDOH across multiple health care systems. They are in an excellent position to develop approaches to integrate health services—aligning hospital, ambulatory, and social service organizations to codevelop processes to link patients with specific social needs or multiple needs.
MMCOs may be particularly well suited to support integrated SDOH approaches. The populations they serve are disproportionately low income and face material deprivations. MMCOs now enroll almost 70% of all Medicaid beneficiaries and have payment models that incentivize decreasing inappropriate health care utilization.
Such efforts can be facilitated through health plan use of a variety of digital navigation tools designed to improve service coordination between the health care system and the social service sector and to better track utilization of services and outcomes outside of clinical settings. Digital platforms and tools have the potential to reduce inefficiencies in siloed health care and encourage integrated care, improve care coordination, quality, safety, and efficiency, and reduce health disparities in targeted populations.
Recommendation 4: Introduce Behavioral Economic Design into Consumer Incentives
Behavioral economic principles can guide benefit design that encourages decreased spending on low-value care. Resulting savings would free up funds that could be directed to selectively develop and test strategies to better address beneficiaries' unmet social needs, thereby reallocating funds toward higher value uses. Approaches that could be helpful include simple co-payment-only plans that ease navigation for members with SDOH, zero cost sharing for high-value services that address clinical or social needs, coverage of cost-effective interventions to reduce social risk factors, and provision of incentives for healthy behavior. To keep the estimated actuarial cost similar to existing plans, high cost sharing for low-value care services could be instituted.
As we have briefly described, there are multiple opportunities for health plans to design and test new strategies that recognize the role SDOH play in worsening health and exacerbating health disparities. A few of these include more systematically collecting data on individual patients, targeting and testing new interventions, aligning with payment transformation efforts, and applying behavioral economic principles to benefit design. By taking these and other steps, health plans could make significant progress in ameliorating SDOH in the coming years.
Footnotes
Author Disclosure Statement
The authors declare that there are no conflicts of interest. The authors received no financial support for this article.