There has been lots of activity by health plans around the social determinants of health—and arranging and/or paying for social services. My question is whether this a passing interest by health plan managers or will this become a permanent shift in health plans service array which will provide a sustainable funding stream for provider organizations.
What has been happening? Eighty percent of health plans moving to make social support part of their service array (see Social Determinants—The Next Frontier). The Health Care Service Corporation (HCSC) and the Blue Cross Blue Shield (BCBS) Institute launched foodQ, a six-month food delivery pilot program (see Blue Cross Launches Food Delivery Program To Address Social Determinants), and the Humana Foundation Dedicating $7 Million To Address Social Determinants Of Health (see Humana Foundation Dedicating $7 Million To Address Social Determinants Of Health). The American Medical Association (AMA) and UnitedHealthcare (UHC) announced a collaboration to support the creation of 23 new ICD-10 codes related to social determinants of health (see AMA & UnitedHealthcare Partner To Propose New ICD-10 Codes To Identify & Address Social Determinants Of Health) and Anthem is making a push to whole person care, as well as person-centered care (see No Whole Person Care Without Person-Centered Organizations).
There are several initiatives coming out of the Kaiser system. Kaiser Permanente last year announced they are investing $200 million in housing projects with the goal of supporting more housing projects in the future (see The Future Of Housing Support) and recently announced a $5.2 million investment in a 41-unit affordable housing complex in East Oakland, California (see Kaiser Permanente Invests In Affordable Housing Complex In Oakland, California For $5.2 Million As Part Of Initiative To Improve Community Health By Addressing Housing Insecurity). And the organization just unveiled plans for a partnership with social coordination platform Unite Us as part of their comprehensive health network-Thrive Local (see Kaiser Permanente Launches Social Services Provider Network). The goal of this new network is “to connect health care and social services providers to address the pressing social needs including housing, food, safety, utilities and more for millions of people across the United States” (see Kaiser Permanente Launches Social Health Network To Address Social Needs On A Broad Scale). The goal is to begin the roll out this summer and expand to Kaiser Permanente’s 12.3 million members and the 68 million people in the communities Kaiser Permanente serves, within three years. The network will track community partner referrals and service outcomes to measure if consumer needs are being met.
The big question—will this be “referrals only” to already overburdened social service programs or will the health plans pay health and human service provider organizations for selected types of social services? And, if health plans are to pay for “non-medical” social support services, this assumes they can get past the immediate hurdle—that the U.S. does not consider certain social services as part health care expenses. The recent changes to the Medicare Advantage plan rule (see The Thinning Line Between Health Care & Social Services) indicate that there may be new funding available for under-funded social services.
One of my concerns is that the health plan interest in social determinants of health has been driven by a decade of the provisions of the Patient Protection & Affordable Care Act (PPACA). No preexisting conditions clauses, behavioral health parity, no annual and lifetime limits, and nearly universal health care coverage has changed the risk management practices of health plans from cost shifting to other service systems to managing the long-term health and well being of enrolled consumers. This could all change if the PPACA is overturned (see Trump Administration Files Formal Request to Strike Down All of Obamacare).
The long-term role of social service initiatives in health plans has yet to be determined, but my colleagues offered a couple of interesting notes. OPEN MINDS Senior Associate Sharon Hicks is cautiously optimistic about the potential—but raises the issue of the decades-long systematic underfunding of social services. She said:
If these recent notices about social determinants of health is signaling a permanent change in the way that we think about taking care of acute and chronic illness, then the money that flows into the supportive services, which are important to the success of the medical care received, will serve to increase the capacity for service delivery.
If, however, the medical/insurance community continues to question the value of the supportive services and refuses to pay a fair value for the delivery of the services, then we are likely to experience a tremendous shortage of availability of these types of services. The market for the services has been inappropriately deflated by the current models of compensation for staff. If that doesn’t change, then the addition of these SDH-focused services will likely fail to realize significant improvements in outcomes for this country.
My colleague Deb Adler, OPEN MINDS Senior Associate, links the future of these initiatives to the ability to demonstrate return-on-investment (ROI)—a topic we’ve covered before. She noted:
I do think payers will go beyond a referral only model, but I suspect it may take some time to transform payer thinking. I suspect the Medicaid managed care programs or divisions within large payers are already leading the pack. It’s wise guidance to demonstrate value to payers as there are social service disruptors out there who may be more nimble, effective (read: less caught up in the “way things have always been done”), and willing to compete with traditional social service providers for the opportunity to provide these services as part of their business model and social mission.
I wouldn’t underestimate the time it will take to prove a return-in-investment and the challenges. Social service needs are complex and not binary (it’s not like you have unstable housing and then “flip a switch” and have stable housing). And statistically there can be a high mortality or “drop-out rate” of the population that is the target focus, which makes the analysis that much more difficult.
A recent payer was hesitant to enter into a shared savings arrangement tied to implementing interventions tied to SDH because they felt it would be difficult to determine if the improvement was a “regression to the mean” or actual improvement. A charitable backer of the program wanted to have a simple “start” and “stop” point for the program to more easily measure impact when the reality is it was unrealistic to use the same “point in time” for individuals targeted to move from a homeless situation to stable housing. Statistically this all can be managed but it illustrates that barriers remain in moving to payment for social service interventions.
For those social support services that health plans may pay for, provider organization business development teams need the same type of approach used for any payer contract development (see Health Plan Business Development For The Entrepreneurial Provider Organization-Step-By-Step). The key-get your proof of return-on-investment (ROI) for your social service supporting services ready (see Social Services ROI Essential To Social Determinants Wave). Any provider organization management team out there that thinks their “social services-infused approaches” to health care will become a long-term market differentiator need to get their “proof” ready now. Without it, the long-term programmatic approaches adopted by payers and health plans will use someone else. I think it’s just as I’ve said before-this is a big opportunity for someone (see A Big Opportunity For Someone).
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
- Screening Humana Medicare Advantage Members For Social Determinants Of Health Reduced ‘Unhealthy Days’ By 2.7%
- Solera Health Raises $42 Million To Address Chronic Disease, Social Determinants Of Health And Addiction
For more, look for our coverage of The 2019 OPEN MINDS Strategy & Innovation Institute (you can follow our coverage on twitter @openmindscircle #OMstrategy) 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.
And for more on what Kaiser is addressing conditions for health and equity, join me on August 13 at The OPEN MINDS Management Best Practices Institute where Bechara Choucair, M.D., Senior Vice President & Chief Community Health Officer, Kaiser Permanente with deliver our opening keynote-Mind, Body, Community: Kaiser Permanente’s Unique Approach.