The U.S. has historically “separated” the health of an individual from their social circumstances. “Medically necessary” was a term I learned when I first started my career and worked for a health insurance company—not medical, not paid. Soon after, “clinically appropriate” was added to the payment criteria to address level of care—the least restrictive level of care only. But social issues or supports were never in the equation.
That perspective has changed for a couple reasons. Over a decade ago, the fundamentals of health insurance underwriting changed with the Patient Protection and Affordable Care Act. The end of preexisting condition exclusions, the end of annual and lifetime care limits, parity for behavioral health services, and the requirements to accept all applicants eliminated the practice of shifting people with more expensive and complicated health conditions from private health plans to public programs. This situation prompted more investigation about the drivers of use of health care resources. What the research found—health care utilization is driven by a number of factors related to the environment (e.g., poverty), demographics (e.g., gender, insurance status), and mental and physical health (e.g., chronic conditions, serious mental illness, addiction) (see Drivers Of Healthcare Resource Utilization and The 68%). And the pandemic has and will continue to exacerbate the social needs of the U.S. population—more anxiety and depression, loss of housing, loss of income, interrupted education, and food insecurity (see A New Look At Social Determinants, Post-Pandemic and Social Determinants Of Health In The Time Of COVID-19).
The social supports/health connection was the focus of a recent web briefing, Population Health: Clinical & Administrative Implications, on our PsychU online community, featuring three of my colleagues, OPEN MINDS senior associates Sharon Hicks and Paul Duck, and OPEN MINDS Vice President Richard Louis, III. They discussed how health plan managers have acted on this emerging body of data and are investing in social support services as a tactic for reducing member spend. A just-published survey of social service investments by Medicaid health plans in Texas and California, Comparison Of SDOH-Related Investments By Texas And California Medicaid Health Plans, confirmed this trend, finding that all of the Texas plans addressed food insecurity and transportation, while 71% of plans addressed housing issues. In California, housing instability was addressed by 84% of plans, while lack of transportation and food insecurity were addressed by 79% and 74% of plans, respectively. There are many examples of these health plan initiatives in our recent coverage:
- Humana has a number of initiatives focused on social supports. They launched a value-based program that pays provider organizations for social determinants of health (SDOH) screenings; documentation of assessment findings; and connecting the member to appropriate resources (see Humana Medicare Advantage Plans To Pay Providers To Address Social Determinants Of Health and Humana Launches Innovative Value-Based Program To Address Social Determinants Of Health). They have also continued their “Bold Goal” initiative, launched in 2015 (see Performance Of Humana ‘Bold Goal’ Social Determinants Program Continues To Improve At Five-Year Mark), with two additional cities (Cincinnati, Ohio and Detroit, Michigan) announced in May 2020 (see Humana Announces Additional Bold Goal Communities In Cincinnati & Detroit).
- CVS Health/Aetna launched a collaboration with Unite Us to develop a social determinants of health platform and connect Aetna Medicaid members with a coordinated network of local social service provider organizations (see CVS Health Announces ‘Destination: Health,’ A New Platform Addressing Social Determinants Of Health).
- Kaiser Permanente created a three-year initiative with Community Solutions to end chronic homelessness in 15 communities (see New Partnership Aims To End Chronic Homelessness In 15 Communities).
- Horizon Blue Cross Blue Shield of New Jersey announced a demonstration project to assist community health workers in addressing SDOH through an online platform, NowPow (see Horizon New Jersey Health Completes Expansion Of ‘Neighbors In Health’ Program To Address Social Determinants Of Health).
- Optum has a new partnership with Wider Circle and Helping Hands Community Partner—“Community Food Circle”—providing Optum beneficiaries in Los Angeles with healthy food amid the COVID-19 pandemic (see Optum, Wider Circle & Helping Hands Community Partner To Deliver Food To Vulnerable People In Los Angeles County During COVID-19 Pandemic).
And, at a broader level, The Centers for Medicare & Medicaid Services (CMS) has recently allowed payment for services for “social needs” out of Medicare Advantage health plan savings (see ‘Leaning In’ To Medicare: Social Needs Opportunities). This is the first time that CMS has broadened the definition of services that can be paid with Medicare funds.
Many traditional specialty provider organizations have a long history of, and great expertise in, addressing the social needs of consumers. How do those organizations meet the emerging market need for connected health and social services and improve their market positioning? My colleagues offered some advice.
Include this expertise in your market positioning—If your organization has expertise in addressing the social support needs of consumers, do health plans managers and other payers know about that expertise? This is a matter of market positioning—understanding whether or not that expertise is a real market differentiator. And, if it is “repositioning,” how you present your organization and your brand—focusing on that expertise and attracting new referrals (see Building A New Value Proposition: Strategy & Positioning For Sustainability).
Provide linkages to social support services to all consumers—whether in fee-for-service or value-based initiatives—In your current services, providing referrals and supports for consumers to meet their social support needs is just good business. It results in better consumer outcomes and is a differentiator for health plans. As Ms. Hicks noted, a clinical social worker may not be able to find housing for a consumer, but they can easily arrange a contact with staff at a community-based organization that can. Social needs assessment and social services referrals can be built into standard clinical practices (see Social Services ROI Essential To Social Determinants Wave).
Develop targeted approaches to social services for value-based contracts and measure their impact—If your organization has value-based contracts, your management team (like the management teams of health plans) should be thinking about what social support services could improve performance and improve profitability. And any initiative needs a financial analysis of costs and likely returns—and a return-on-investment analysis of whether the predicted financial gains are achieved.
Evaluate the creation of new social support service lines focused on the needs of health plans and other payers—It’s clear health plans and other payers are investing in social services, but what exactly are they looking for? Our 2019 survey of health plans, Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System, found that 27% of health plans are investing in initiatives to improve access to affordable housing and 21% are investing in transportation initiatives. Thirteen percent are investing in food insecurity. To decide whether your organization should invest in a new service line focused on social supports requires the same process as developing any other service line- market research to determine specific needs, assessment of the competition, operational and financial feasibility analysis, and a marketing launch plan (see How To Develop A New Service Line: An OPEN MINDS Seminar On Building A Diversification Strategy & Conducting A Feasibility Analysis and How To Develop A New Service Line: An OPEN MINDS Executive Reading Book On Building A Diversification Strategy & Conducting A Feasibility Analysis). The key, as Mr. Louis underscored, is to first understand your organization’s current ability to provide social support programs—then come together with the community to better understand the needs of consumers while aligning the strategic initiative with the goals of the health plan or payer.
For more on strategic positioning for SDOH and population health management, check out these resources in The OPEN MINDS Industry Library:
- Ten Essential Public Health Services & How They Can Include Addressing Social Determinants Of Health Inequities
- Nextdoor Launches Global Campaign To Unite Neighbors Against Loneliness & Social Isolation
- Children Were 69% Less Likely To Be Hospitalized After Their Families Worked With A Volunteer Navigator To Connect Them With Social Services
- Nevada Launches COVID-19 Aging Network Rapid Response To Respond To Older Adult Social Isolation
- Georgia Division Of Aging Services To Use $1.7 Million Grant To Increase Access To Services & Reduce Social Isolation
- Social Determinants Of Health 101 For Health Care: Five Plus Five
- Caring For Vulnerable Populations In A Social Distance World: Autism Service Providers Implement Virtual Care Delivery
- Unite Us & Lyft Partner To Reduce Transportation Barriers & Improve Access To Health & Social Care
- Reentry Programs More Successful When Addressing Social Risk Factors
- One Health Plan’s Partnership Approach To Social Determinants
And for even more on serving complex consumers, join us for The OPEN MINDS Care Innovation Summit: Solving The Problem Of Access For Consumers With Complex Care Needs on August 25 with OPEN MINDS Senior Associate Paul M. Duck.