Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations

Abstract

The objective was to examine Medical Advantage (MA) organizations’ commitment toward addressing social determinants of health (SDOH) through their health-related social benefit offerings, and the perceived impact of providing supplemental benefits associated with SDOH in their plans. Public reporting documents were reviewed from six of the largest MA firms: Humana, UnitedHealthcare, Cigna, Elevance Health, CVS Health, and Centene. Public reports were obtained from each company’s website (eg, from the “Investor Relations” page). Quarterly reports for Q1 2023, annual reports for 2022, and proxy statements for 2023 for all companies were examined. Content analysis of the public reports was conducted under three constructs: (1) Growth of MA in the company, (2) SDOH-related activities in the company, and (3) SDOH-related activities in the MA plans of the company. Each of the three constructs was further analyzed for recurring themes and elements. The findings from content analysis suggests that plans are providing tailored benefits that may address the social needs of vulnerable and underserved populations. Companies that offered supplemental benefits and value-based arrangements that addressed social needs reported beneficiary clinical outcomes resulting in cost savings and increased revenue. Health insurance companies identify MA as a significant growth opportunity and a strategically important market for overall membership and revenue growth. Moreover, companies providing innovative social benefits through their MA plans reported witnessing increased value propositions by underserved and vulnerable populations, leading to increased revenue and cost containment.

Introduction

The Medicare Advantage (MA) program was introduced in 2005 (replacing the Medicre + Choice program created in 1997, which was an evolution of Medicare Part C, which was created in 1973) to bring efficiency and cost savings to Medicare by leveraging private sector-managed care. Previous work shows high beneficiary satisfaction with MA, and enrollment rates in the program have increased over the years.¹ Nationally, Medicare-eligible beneficiaries have increasingly chosen MA products, with 51% penetration in January 2023, representing a market of $473 billion.² Unlike traditional Medicare (TM), MA allows for the use of selective contracting to establish specific provider networks and the inclusion of extra benefits not found in TM, such as dental and vision care, and social needs such as gym memberships, transportation, and meal services.³ Additionally, MA plans typically offer lower premiums compared with TM and feature caps on annual out-of-pocket expenses.⁴ These cost benefits and added features have played a significant role in the swift increase in MA enrollment. With the passage of the Bipartisan Budget Act of 2018, Congress allowed MA plans to offer “special” supplemental benefits (ie, nonmedical) for the chronically ill. Previously, MA insurers were required to cover the same supplemental benefits for all enrollees in a service area (the “uniformity rule”). But, starting in 2020, regulations waived the uniformity requirement for MA plans and allowed insurers to offer tailored benefits to their beneficiaries with chronic illnesses.⁵ Additionally, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2018 provided MA plans the flexibility to offer Special Supplemental Benefits for the Chronically Ill (SSBCI) to address enrollee social needs.⁶

This increased flexibility opened policy opportunities for MA plans to tailor supplemental benefits specific to their beneficiaries’ medical conditions and needs. Initial plan inclusion of the new supplemental benefits was slow,⁷ because of a lack of funding to provide these benefits and the inclusion of supplemental benefits in the medical loss ratio (MLR) calculation. These factors contributed to uncertainty on payments and return on investment (ROI).^8,9 Despite a slow start, since 2020 the number of plans offering supplemental “social benefits” has tripled from 626 to 1,851, and by 2022 34% of MA plans offered at least one nonmedical benefit.¹ This increase in the adoption of special supplemental benefits over time can be attributed to MA plans: (1) constructing innovative benefits that manage the issues of MLR and ROI; (1) partnering with risk-bearing providers; (3) stratifying member populations to tailor benefits toward at-risk patients who most need them; (4) identifying and partnering with best-in-class vendors; and (5) formulating a consumer-driven benefit design that increases profitability and mitigates any risks from the MLR.⁷

This study seeks to advance research on the operations and practices of MA plans, focusing on availability and impact of health-related social benefits. It also examines the capital commitments that MA organizations are making to address social determinants of health (SDOH).

Methods

Sections 13 and 15(d) of the Securities Exchange Act of 1934 established a legal framework that requires publicly held companies to disclose relevant financial information and other significant developments affecting the company’s performance.^10,11 This requirement is intended to ensure transparency and provide investors, analysts, and the public with the necessary data to make informed decisions regarding company financial performance and strategic direction. Public reports from six MA firms were reviewed. Organizations were selected based on the large percentage of Medicare Advantage enrollees they cover. A recent report by Kaiser Family Foundation observed that MA enrollment is highly concentrated in a small number of firms, and that two firms—UnitedHealthcare and Humana—account for 47% of all Medicare Advantage enrollees nationwide.¹² Additionally, CVS Health, Centene, Cigna, and Elevance account for another 19%.¹² Profiling these companies provides a reasonable representation of SDOH-related activities in MA plans.

Public reports were obtained from each company’s website (eg, from the “Investor Relations” page). Quarterly reports (including quarterly earnings reports and earnings call transcripts) for Q1 2023, annual reports for 2022, and proxy statements for 2023 for all companies were examined. While these reports provide valuable insights on operations, financial status, and strategic direction of the company there is a risk of bias and subjectivity on how they present their information. It is important to note that the companies have an incentive to highlight positive aspects while downplaying or omitting negative information. Therefore, the study contextualizes the information obtained from these reports within the broader literature of Medicare Advantage to improve the validity of the conclusions. Additionally, the reliance on payer corporate annual and quarterly reports, as well as investor calls, as primary data sources present some limitations. These sources, while useful, can exhibit significant variability depending on the regional geographies of the MA markets. Also, these reports do not fully capture the nuances and variability of SDOH impacts at a specific population level. The corporate reports and investor communications are primarily designed to inform stakeholders about corporate financial performance and strategic direction rather than provide detailed, unbiased, and comprehensive data on SDOH impacts. Therefore, while interpreting the findings, it is important to consider that they may not represent the full spectrum of SDOH effects and their variability across different geographic, socioeconomic, and demographic segments.

Content analysis was carried out for all the documents under three constructs: (1) Growth of Medicare Advantage in the company, (2) SDOH-related activities in the company, and (3) SDOH-related activities in the Medicare Advantage plans of the company. Under the first construct, two elements were assessed: (1) growth of MA (based on enrollment rates) from March 2022 to March 2023 and (2) the identification of MA plans as a significant growth opportunity. Under the second construct, five themes were assessed to evaluate whether the company: (1) provides health plan products and services that create pathways for addressing SDOH, (2) prioritizes community collaborations/partnerships/navigators to screen and address social needs, (3) incorporates SDOH as a strategic priority to address health disparities, (4) focuses on value-based care models, and (5) attributes enrollment growth (in part) to community-based offerings. Under the third construct, five themes were assessed to evaluate whether the MA plans of the company: (1) meaningfully support underserved populations by addressing social needs, (2) identify opportunities to improve services to enrollees who are burdened disproportionately by social risks to health, (3) provide value-based arrangements that involve social needs, (4) include programs that support social needs as a part of their program, and (5) identify social needs as “competitive positioning” providing “unique capability” for growth.

Results

Company MA enrollment changes from March 2022 to March 2023 are reported in Table 1. All six companies reported that their MA enrollment had consistently grown over the years and their projections anticipated enrollment increases in the coming years as well. Humana and CVS Health projected the highest MA enrollment growth rates, estimated to be 17% and 12%, respectively, by the end of 2023.^13,14

Table 1.

Medicare Advantage Enrollments

Company	Enrollment change from March 2022 to March 2023
Humana	11%
United Healthcare	9.5%
Elevance Health	7%
CVS Health	7%
Cigna	6%

Percent changes were obtained from company’s first quarter 2023 financial results.^{13,20,21,39,22}

MA enrollment numbers for Centene could not be found (they provided enrollment numbers for all Medicare plans combined).

Growth and success of medicare advantage in the company

The results from content analysis indicate that all six companies identify MA plans as a significant growth opportunity and a strategically important market due to their plans’ strong competitive positioning, their unique capabilities, and a highly attractive market (Table 2). The competitive strengths of MA reported by the companies include benefits that target social needs of seniors (Humana, United, Cigna, Centene),^15

–18 scalable services that address SDOH and support underserved and vulnerable populations (Humana, Cigna, Elevance),^15,17,19 and clinical care models and value-based care arrangements that support social needs (Humana, United, CVS Health).^14
–16 Additionally, Humana, United, Cigna, and Elevance all indicated that their revenues were primarily driven by their MA products and membership growth.^{13,15
–17,19

–22} These companies consider MA as an important line of business and heavily focus on expanding it as a part of their business plan.

Table 2.

Content Analysis of Investor Relation Reports of the Companies

	Humana	United Health	Cigna	Elevance Health	CVS Health	Centene
MA success in the company
Company reported increased enrollment in MA plans	Yes	Yes	Yes	Yes	Yes	Yes
Company identifies MA plans as a significant growth opportunity ahead	Yes	Yes	Yes	Yes	Yes	Yes
Company’s focus on community and social needs
Company’s health plan products and services are creating pathways for addressing SDOH and health-related social needs	Yes	Yes	Yes	Yes	No	Yes
Company prioritized community collaborations/partners and community navigators to screen and address social needs	Yes	Yes	Yes	Yes	No	Yes
Company addresses SDOH as a strategic priority to address health disparities	Yes	Yes	Yes	No	No	Yes
Company has a heavy focus on value-based care models	Yes	Yes	Yes	No	Yes	Yes
Company’s growth attributed to community-based offerings	Yes	Yes	No	No	No	No
MA plans focus on community and social needs
MA plans meaningfully support underserved populations by addressing social needs	Yes	No	No	Yes	No	Yes
MA plans identify opportunities to improve services to enrollees who are burdened disproportionately by social risks to health (health equity)	Yes	Yes	No	Yes	No	Yes
MA plans provide value-based arrangements that involves social needs	Yes	Yes	Yes	No	No	No
MA plans have programs that support social needs	Yes	Yes	Yes	Yes	No	Yes
MA plans identify social needs as “competitive positioning” and “unique capability” for growth	Yes	Yes	No	Yes	No	No

SDOH-related activities in the company

The analysis of SDOH-related benefits provided by companies suggests that five out of six companies are creating pathways for addressing SDOH and health-related social needs through their health plans’ products and services. These pathways inform all company offerings and are not necessarily limited only to their MA plans. Five out of six companies indicated that they prioritized community collaborations and partner/community navigators to screen and address social needs. For example, Humana’s 2022 annual report stated that they are continuously working to remove barriers to health by addressing social needs through deep community collaborations and establishing processes to screen patients for social issues such as food insecurity.¹⁵ In their 2023 proxy statement, UnitedHealthcare proposed partnering with community organizations, including federally qualified health centers, public housing authorities, food banks, schools, and other non-profit organizations as their long-term strategy to advance health equity.¹⁶ Cigna stated that they reward value-based providers for screening for social needs, making appropriate referrals for support, and identifying health disparities impacting their patient population by giving them “market competitive base salaries and incentives”.¹⁷ Elevance launched community service centers that include resources on housing, employment assistance, legal aid, and other programs such as the Supplemental Nutrition Assistance Program. Free food and diapers are other essentials that they provide to address the social needs of their members.¹⁹ Centene invested in communities to strengthen initiatives focused on health care access, education, and social services for their members.¹⁸ These investments include initiatives like sponsoring community gardens and organized farmers markets, and providing housing placement services in their state health plans. Four of the six companies (Humana, UnitedHealthcare, Cigna, and Centene) indicated that they target SDOH as a strategic priority to address health disparities and achieve health equity.^15

–18 Cigna’s 2023 proxy statement highlighted their longstanding focus on reducing disparities by addressing SDOH by partnering with health care providers and community organizations.²³ An example of their effort to reduce disparities is a preterm birth program in collaboration with Baltimore, Houston, and Memphis community organizations focused on reducing pregnancy-related complications among African American women. Five of six companies indicated that they focus heavily on value-based care models. The findings suggests that the companies used value-based care to address social needs by integrating primary care in underserved areas,¹⁵ accelerating value-based care in the home,¹⁵ rewarding value-based providers for social needs screening,^16,24 and meeting consumer needs by providing supplemental benefits through value-based arrangements.^14,18

SDOH-related activities in medicare advantage plans

The analysis of SDOH-related activities by MA plans showed that three out of six companies (Humana, UnitedHealthcare, Elevance) indicated that their MA plans: (1) support underserved populations by addressing social needs and (2) identify opportunities to improve services to enrollees who are disproportionately burdened by social risks to health. Humana implemented the “Go365” program in which members that complete health and fitness activities get rewards that can be used for groceries, gas, and other social needs.¹⁵ UnitedHealthcare implemented an in-home clinical care model called “HouseCalls” that conducts special social needs assessments, connects MA beneficiaries to social services, integrates card benefits to help older adults pay for food and utilities, and maintains community partnerships that provide access to healthy meals, employment opportunities, affordable housing, social isolation solutions, and transportation to doctor visits.²⁴ Elevance, in their earnings call transcript, reported that social factors such as whole health and health equity remain core to their MA programs, and they specifically tailor services for members that are underrepresented and socially vulnerable.²⁵

Three out of six companies (Humana, UnitedHealthcare, and Cigna) indicated that they provide a value-based arrangement involving social needs in their MA program.^15
–17 Cigna initiated a partnership with VillageMD (a developer of primary care clinics) to accelerate value-based services in which providers are rewarded for screening for social needs and making appropriate referrals for MA members that receive medical care from the company’s value-based arrangements.¹⁷ Humana’s MA value-based arrangements include screening for social health needs, providing health food cards to buy groceries, transportation benefits, community support programs, and referrals through Humana community navigators.²⁶ In 2022, UnitedHealthcare reported serving approximately 1 million more members in fully accountable value-based care models in their Medicare Advantage models which included an integrated benefits card that provided health benefits that help older adults pay for prescriptions, food, and utilities.²⁴

All reviewed companies, except CVS Health, reported that their MA plans support social needs as part of their program. Amongst those, three companies (Humana, UnitedHealthcare, Elevance) stated that offering social benefits to their members provides “competitive positioning” and “unique capability” for growth. For example, Humana positioned addressing social needs within their integrated care delivery model.²⁷ Some of their approaches for addressing social needs in their MA value-based care include health food cards, provision of transportation, and incentives to take up social and health education activities, including fitness events and workouts through their Go365 reward programs.^28,29 Similarly, UnitedHealthcare and Elevance indicated that MA is an important long-term business, and they plan to continue providing high-value offerings, such as supplemental (social) benefits, social needs screenings, and community partnerships, to attract more members.^16,19,25,30

Discussion

Most of the companies analyzed identified MA as a significant growth opportunity and a strategically important market for growth in their overall membership and revenue. The companies showed increased MA enrollment rates from 2022 to 2023. The findings from the content analysis suggested that the growth in MA membership is attributed, at least in part, to MA plans providing tailored benefits that address the social needs of vulnerable and underserved populations. Previous studies indicated that MA plans provide tailored benefits to address their enrollee’s social needs as an incentive to reduce avoidable health care utilization and contain costs.^6,31 A study that interviewed representatives from 17 diverse MA plans noted that offering a new supplemental benefit to address SDOH is a way to meet consumers’ needs and expectations, allowing plans to be more competitive in the marketplace and increase their membership.³¹

The study findings suggested that MA plans increased the value proposition to their senior consumers, underserved individuals, and vulnerable populations by offering products that address their unmet social needs. A national survey of older adults enrolled in MA reported a high burden of health-related social needs such as food insecurity, poor housing quality, and financial strain.³² Moreover, these needs are unevenly distributed, with disparities based on race and socioeconomic status.³² Findings from UnitedHealthcare reports revealed that their MA enrollment among minority populations has more than doubled since 2013, and as of 2022, they make up more than 30% of their MA membership.^16,20,30 Humana reported that they prioritize assistance for underserved communities noting that the majority of Hispanic Americans and almost half of African Americans opt for an MA plan.^15,26 Additionally, they state their ongoing efforts make their health plan offerings and services as cost-effective as they can be while creating pathways for access to health care, tackling SDOH, and addressing health-related social needs.¹⁵

Although the companies reviewed in this study state that addressing the social needs of their beneficiaries increases the value proposition, there might be additional underlying motivations prompting them to incorporate social needs into their MA plans. For example, the “house calls” program by UnitedHealthcare conducts risk assessments, which have been reported to result in upcoding and over payments.³³ Most of these companies also offer gym and fitness memberships, which could exacerbate the already existing issue of favorable selection by attracting healthier beneficiaries.³⁴

The study notes that few of the companies that observed increased revenue and cost savings attributed these benefits to their MA plans offering supplemental social benefits. Humana, in their 2021 cost analysis, estimated that members in MA value-based arrangements that include supplemental benefits saved approximately six billion dollars (20.1%) in medical costs that they would have incurred had they been enrolled in TM.²⁶ UnitedHealthcare reported that their membership growth was primarily driven by their MA program, which also incorporates innovative benefits that address SDOH in diverse, lower-income, and clinically complex populations.³⁵ Additionally, they report 40% lower costs for MA beneficiaries than those in TM in 2021.³⁰ Careful interpretation is required while comparing TM and MA given the selection bias associated with these comparisons.³⁶ Moreover, lower spending associated with MA plans is more likely a result of utilization management techniques and the implementation of restrictive networks specifically tailored for MA patients.³⁷ Therefore, attributing lower spending and cost saving to supplemental social benefits requires a more nuanced examination that considers these underlying factors.

The study findings have several policy implications. First, a high burden of health-related social needs in older adults demands continued focus on offering benefits to meet food insecurity, in-home support services, transportation, and other needs.⁹ That burden will also require innovating MA products to expand social benefits and provide flexible benefit designs targeting the needs of beneficiaries.² Second, the uneven distribution of social needs across the population based on race, income status, and geographic location supports further experimentation with social risk adjustment in MA and Medicare’s value-based insurance design.³² Third, companies experiencing increased revenue and cost efficiency through their Medicare Advantage plans focused on social needs are anticipated to place a higher emphasis on supplemental benefits and value-based agreements targeting SDOH. Finally, there is a lack of standardized tools for identifying social needs, payment mechanisms for interventions to address those needs, and outcome evaluation methods in MA programs that provide SSBCI.³⁸ Stronger guidance and new standards on SDOH information collection by CMS can support MA companies that heavily focus on providing SSBCI and value-based arrangements.

The study should be interpreted in the light of several limitations. First, the study relies on self-reports to shareholders to document what MA organizations are doing. While this is a good source to observe the commitment of addressing SDOH in MA organizations, it should be considered as a corporate statement, not an independent assessment. Some of the statements provided specific evidence of investment to address SDOH, which can be taken at face value. Second, the study focuses on only one dimension of benefit design and does not address the impact of narrow networks, cost-sharing (deductibles, copayment), claims denial, and provider payment. Therefore, this is not an assessment of the total/overall value of MA plans to beneficiaries. Given these limitations, one cannot independently assess claims that financial success is influenced by efforts to address SDOH. Other MA Plan actions, such as narrow networks, provider payment, and claim denial may have a greater impact on financial success. Lastly, it cannot be confidently asserted that the firm-level reporting is accurate across all service areas.

Conclusion

Companies have seen consistent growth in MA membership over the years, and their projections suggest that they will continue to see increasing enrollment in the coming years. Hence, MA plan design, including covered benefits, is an important opportunity to incorporate benefits addressing SDOH. Potential for encouraging MA plans to address health-related social needs was acknowledged in the CHRONIC Care Act of 2018. Most of the MA organizations emphasized the strategic significance of addressing SDOH, both in a general context and specifically within MA. Moreover, most of the companies providing innovative social benefits through their MA plans witnessed improved clinical outcomes and increased value propositions by underserved and vulnerable populations. Further investigation is necessary to determine whether these social benefits actually enhance health outcomes and reduce costs for enrollees or whether they predominantly serve as a strategic marketing tactic to entice lower-cost enrollees by offering appealing incentives. Regardless of the situation, companies may continue to deliver MA plans that include addressing the distinct social needs of various populations to enhance clinical outcomes, control costs, boost revenue, and promote health equity.

Ethics/Consent Statement

The study did not require an ethics board approval because this study does not report animal and human studies or any other human interventional components that requires ethical clearance.

Footnotes

Authors’ Contributions

K.G.: Conceptualization, methodology, formal analysis, investigation, writing—original draft preparation. F.U.: Conceptualization, methodology, investigation, writing—review and editing. K.J.M.: Conceptualization, funding acquisition, writing—review and editing, supervision.

Author Disclosure Statement

The authors declare that they have no relationships that may pose a competing interest.

Funding Information

This work was supported with funds from the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), and the U.S. Department of Health and Human Services (HHS) under cooperative agreement/grant #1U1C20419.

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