There is a thinning of the previously absolute line between “health care” and “social services.” We’ve written about that absolute line between the two before—Social Determinants Today, Social Determinants Tomorrow, Social Services Paid By Health Plans?, and Health Care Spending Vs. Social Service Spending. The rigid line never made sense from a practical perspective—but it does take policy a while to catch up with practice.
This shift started nine years ago with the advent of the Patient Protection & Affordable Care Act (PPACA). Its elimination of preexisting condition clauses and annual/lifetime limits on benefits changed the lens for thinking about consumer wellbeing and resource use. Roll forward a decade—last fall the Centers for Medicare & Medicaid Services (CMS) announced that Medicare Advantage plans will be able to offer supplemental benefits that are not necessarily health-related (see Why New Medicare Rules For ‘Non-Medical Benefits’ Matter).
Now CMS has put out the details of that shift in the 2020 Medicare Advantage Rate Announcement and Final Call Letter (see Medicare Advantage To Offer Supplemental Benefits For Social Determinants In 2020). Starting in 2020, under this expanded definition, Medicare Advantage plans can cover new services, with the goal of keeping consumers in the community. These services may include:
- Transportation services for health-related appointments, such as a physician office, a nutritionist, or a chronic condition education program
- Meal delivery and nutrition services
- Adult day care services
- Memory fitness programs
- Personal care services and home modifications to assist with activities of daily living, such as adding railings or supports in the bathroom
Tools or services that fall within this expanded definition must be recommended by a licensed medical professional as part of a consumer’s care plan and be “focused directly on an enrollee’s health care needs”֫—meaning that they will help promote a healthier lifestyle, help to improve the impact of health conditions, or reduce utilization of health care services.
These changes from CMS point to a system redefining what the term “health care” means—and that absolute line is fading. As that definition continues to be broadened, the opportunities for provider organizations will expand as well. The question for provider organization executive teams is how to leverage these coverage changes when planning future revenue diversification and sustainability. For provider organization strategy, think there are three big takeaways from this shift.
First, provider organization management teams will need to build more robust case management and care coordination services. “Best practice” services will include comprehensive consumer screening for social determinants of health and assessments for social support needs. And, case managers and clinical professionals will need to develop more inclusive, person-centered care plans that address the needs of the whole person and build better community connections to refer consumers to additional support needs.
Second, these same management teams will need to develop new services (or enhance existing services) to meet the needs of the health plans that have been charged by CMS with covering these supplemental benefits. The nutrition/meal delivery services could be an interesting expansion for any home-based care programs-one more billable service to offer to current customers. Adding memory care services or adult day care is a new service that can supplement existing programs for seniors, especially those with co-morbid chronic conditions, to help keep them living in the community. With this added flexibility, health plans will be looking for new solutions—and entrepreneurial provider organizations have the opportunity to provide those solutions (see From Pain Point To Revenue and The OPEN MINDS Health Plan Partnership Summit: A Guide To Developing & Negotiating Partnership Agreements With Health Plans). But I will add that selecting and developing new services and service line extensions demands a structured approach to both market analysis and investment.
Finally, there is the return-on-investment (ROI) issue. It is important to note that just because health plans can underwrite selected social supports for consumers doesn’t mean they will. As we wrote about earlier, determining the ROI of social support programs will be critical for taking a new program model to scale. There are a few basic steps, outlined in my previous article, Selling Social Services To Payers & Health Plans: A Step-By-Step Approach. Pilot projects are great, but just the first step on this journey. The pilot project needs to be designed to measure performance and conduct an ROI analysis for your organization’s service. Without a solid ROI, your approach runs the risk of becoming another one-time interesting experiment without long-term adoption.
For more information to get your team thinking about new programming integrating social services, check out these resources from the OPEN MINDS Circle Library:
- The Social Services Market: Over $331 Billion In Spending In FY2016
- Addressing Social Determinants-The Measurement Challenge
- Social Determinants Today, Social Determinants Tomorrow
- Social Determinants Of Health & Medical Homes
- Addressing The Social Determinants Of Health With Income Assistance
- Medicare’s Path To Incorporating Social Determinants Into Value-Based Payment
- Humana Foundation Dedicating $7 Million To Address Social Determinants Of Health
- Social Determinants Of Equity & Social Determinants Of Health
For more, join us on at The 2019 OPEN MINDS Strategy & Innovation Institute, where OPEN MINDS Senior Associate John F. Talbot will present, Taking Action On Social Determinants: New Social Support Models For Consumers With Complex Conditions, featuring Amber Rich, Community Partnership Specialist, Intermountain Healthcare; Angela Choberka, Community Partnership Specialist, Intermountain Healthcare; and Tracy Luoma, Executive Director, Optum Salt Lake County, Optum Consumer Solutions Group.