In the past two weeks, almost every discussion that I’ve had about planning for future sustainability has, in some form or fashion, involved a discussion about “the safety net.” However, the discussion was really about our two safety nets in the United States—the health care safety net and the social safety net (see Virus Imperils Health Care Safety Net and The Social Safety Net: The Gaps That COVID-19 Spotlights). These are not academic discussions—because whatever happens now and in the near future with our safety nets is going to have a significant impact (either positive or negative) on any organization entering into some type of value-based contract for services.
The pandemic has pointed out the shortfalls in our safety nets. An estimated 5 million people have lost their health insurance coverage since February (see Millions Have Lost Health Insurance In Pandemic-Driven Recession), with the overall uninsured rate expected to increase by about 10%, from 28.6 million before the emergency to 31.5 million (see COVID-19 Job Losses & Recession Projected To Raise Uninsured Rate From 10.4% To 11.4%). And, with the CARES Act funding at an end, income support for the 53 million unemployed people is also at an end. And, no amount of food banks and eviction/foreclosure protections are going to fill the gap. This is happening at time when state and local budgets foretell significant cuts to all budgets (see Estimated City Shortfall Hits Combined $2 Billion For This Year And Next, Florida’s Deficit Grows To $5,400,000,000 Over Next Two Years Thanks To Pandemic, and US Budget Deficit Hits Record $3 Trillion Through 11 Months).
In my recent conversations with payer managers—Medicaid directors, county health directors, and health plan managers—there is a recognition that the lack of safety nets is going to “bend the cost curve” negatively in the very near future. As we look to next year, the number of people on Medicaid rolls and the number of people uninsured is almost certain to increase. In addition, the number of consumers inadequately housed, with food insecurity, and in need of transportation assistance will also increase. This will put the pressure on payers to fund programs that address these social factors (in order to reduce unnecessary health care spending) and on provider organizations to develop some innovative approaches to these problems that have a measurable return on investment.
In the year ahead, we’ll be covering these budget issues and their impact on funding health and human services for consumers. And, we’re planning to feature both changes in payer and health plan policies to address social determinants—and the innovative programming in the service delivery system that takes the “whole person” concept to new levels. To get started with this discussion, we’ve compiled the latest findings and activities on addressing SDOH from The OPEN MINDS Circle Library and our online communities.
The Case For Addressing SDOH: By The Numbers
The increased need for social supports is going to run head long into the likelihood that budget-strapped payers are going to look to more managed care and value-based reimbursement to improve value for health care spending. The challenge is that almost a third of the organizations managing risk-based contracts report that addressing social determinants is the greatest challenge to managing the arrangements. Like many crises, there are opportunities for some provider organizations in this intersection of social services and health care. Health and human service organizations operating under risk-based or value-based agreements (health plans, accountable care organizations, health systems, etc.) are going to be more focused on policies that expand the social safety net, on connecting consumers to those social safety net services, and determining a return-on-investment for paying for selected social services.
Data show that 80% of health care spending is driven by personal, social, and environmental factors, not health services. Robert M. Atkins, M.D., MPH, senior medical director of Aetna Medicaid, addressed this issue during the 2019 OPEN MINDS Executive Leadership Retreat (see Building A Trauma-Informed Informed Network—One Health Plan’s Approach) and explained Aetna’s strategy for exploring trauma-informed provider organization networks.
A recent report from the U.S. Government Accountability Office (GAO) found that social determinants are a major impediment to managing care for high-cost Medicaid beneficiaries. The biggest impediments include a lack of transportation to medical appointments, lack of stable housing, and inconsistent access to food and other basic resources. Additionally, a study by Kaiser Permanente found that 68% of their members—across commercial, Medicare, and Medicaid—have an unmet social need (see The 68%). The challenge then for provider organizations is to figure out how to best address these needs and turn that skill into an opportunity for partnerships with a payer.
Social factors are primary impediments to managing care for high-cost Medicaid beneficiaries. These factors create barriers that impede beneficiary participation in care management services, creating challenges for states trying to improve outcomes and reduce costs for high-expenditure Medicaid beneficiaries. The biggest barriers include lack of transportation to medical appointments, lack of stable housing, and inconsistent access to food and other basic resources. Additional barriers to effective care management include staff shortages in rural areas and state or Medicaid managed care organization (MCO) difficulties contacting beneficiaries due to outdated contact information or limited beneficiary mobile phone minutes.
The state of Pennsylvania has reported that permanent supportive housing (PSH) for the state’s Medicaid beneficiaries reduced total Medicaid spending by 13% per person per month between 2011 and 2016. This equaled a decrease in Medicaid spending of $162 per person per month by the third year after PSH entry, relative to changes in a matched comparison population with similar characteristics who did not receive PSH. PSH programs provide long-term housing assistance and support services to individuals with disabling physical and mental health conditions experiencing chronic homelessness.
Payer-Driven SDOH Initiatives
“Behavioral health provider organizations can provide the best possible care but those consumers who remain on the streets will never get better, unless they secure affordable housing,” said Andy McMahon, Vice President, Health and Human Services Policy, UnitedHealthcare Community & State, keynote speaker at the OPEN MINDS Management Best Practices Institute. He suggested that health and housing provider organizations must forge connections and seek opportunities through ongoing collaboration and see how best to support each other’s “vested interests.” For example, behavioral health provider organizations can bill Medicaid—under 1115 waivers—for “tenancy support services” to help consumers find and stay in rented housing. And for provider organizations, this is another pipeline for referral development. Ultimately, it’s all about partnerships for better outcomes.
On June 2, 2020, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) announced it had expanded its Horizon Neighbors in Health (HNIH) demonstration project and partnered with six health systems to expand the program to members in 70 ZIP Codes across 11 counties. Atlantic Health Systems, Hackensack Meridian Health, RWJ Barnabas Health, the Trenton Health Team, University Hospital, and St. Joseph’s Health received grants to hire and train local community health workers. The community health workers use an online platform called NowPow to connect Horizon BCBSNJ members with an array of non-medical services such as food, housing, mental health support, education, or employment opportunities. The program is intended to help Horizon BCBSNJ members connect to services and resources, obtain what they need to improve their health, and maintain the connections independently.
Optum, a leading health services company, and Wider Circle, a tech-enabled community-based health care services company that drives better health for older adults and other vulnerable communities, have partnered with Helping Hands Community (HHC) to launch the “Community Food Circle” initiative to bring food to thousands of Optum consumers in Los Angeles County during the COVID-19 pandemic. The initiative supports Optum’s goal of helping people reach their health and well-being goals, including addressing social determinants of health.
On March 4, 2020, Humana announced it had launched a Medicare Advantage value-based program (VBP) focused on addressing member social determinants of health (SDOH) such as food insecurity, social isolation, loneliness, and housing instability. The first participating provider organization is Ochsner Health, a large non-profit, academic health care system in Louisiana. A Humana spokesperson said the insurer intends to expand the program to include participation elsewhere in the country; however, the company does not currently have a set timeline for expansion.
The Anthem Blue Cross and Blue Shield Foundation announced new Ohio grants totaling $260,000 to Ohio-based Boys & Girls Clubs, Feeding America organizations, and the Children’s Hunger Alliance to address food insecurity in the wake of COVID-19. The grants are part of a $2 million commitment that Anthem Blue Cross and Blue Shield and its Foundation have made to support non-profit organizations on the front lines of the pandemic. The Foundation has been working with partner nonprofit organizations to support emergency response, food access, personal protective equipment supplies, education, cancer support, and virtual youth programming. Approximately $1.1 million has already been committed to organizations across the state, with another $900,000 slated for emerging needs in the coming weeks and months.
More SDOH Interventions & Resources
Seventy-eight unique programs, involving 917 hospitals nationwide, spent $2.5 billion on programs focused on social determinants of health (SDOH) between January 1, 2017 and November 30, 2019. SDOH is defined as topics concerning economic stability (employment, poverty, housing instability, food insecurity); education (early childhood education and development, high school graduation, enrollment in higher education, language, literacy); social and community context (civic participation, discrimination, incarceration, social cohesion); health and health care (access to health care, access to primary care, health literacy); and neighborhood and built environment (access to foods that support healthy eating patterns, crime and violence, environmental conditions, quality of housing). Approximately $1.6 billion was spent on 52 programs that were committed to housing-focused interventions.
Researchers with the Centers for Medicare & Medicaid Services (CMS) have developed a 10-item screening tool to identify health-related social needs. The tool focuses on five domains that can be addressed through community-based services: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety.
Massachusetts is implementing its new $56 million initiative to address food insecurity created by the coronavirus disease 2019 (COVID-19)-related disruptions to the food system supply chain. The initiative includes a $36 million Food Security Infrastructure Grant Program to address food insecurity in the commonwealth, as well as $20 million to strengthen its food distribution systems. The grant program seeks to ensure that individuals and families have equitable access to food, especially local food. The grantees can use the funds to purchase technology; equipment and supplies; increased capacity to produce, store, or deliver food; and other assistance to help producers distribute food, especially to food insecure communities.
South Ward Children’s Alliance (SWCA) announced that it has partnered with Lyft to provide access to transportation for residents who live in the South Ward district of Newark. Using a designated code distributed by SWCA, residents will have access to rides up to $25. The partnership is part of LyftUp, Lyft’s comprehensive effort to expand transportation access to those who need it most. In response to the COVID-19 crisis, Lyft has activated more than 500 LyftUp partners, including public health entities, local governments, nonprofits and community organizations, like SWCA, to provide free rides and free delivery of essential goods for vulnerable communities and critical workers.
Unite Us, a technology company that builds coordinated care networks to connect health and social care provider organizations, announced that it has joined forces with Lyft, the leading transportation network with national experience in health care, to provide ride-enabled referrals through the Unite Us platform. Coordinators and service provider organizations who use Unite Us to make electronic social care referrals can now order or schedule a Lyft ride on-demand to help consumers access the care they need to live healthier lives.
As of January 2020, Sutter hospitals and care centers around Northern California will have the option to start implementing customized, individual transportation programs — an important next step in simplifying access to care. This partnership with Lyft allows different care sites to customize their rideshare services to best support their communities. For example, in more rural areas where transportation options historically aren’t as reliable, patients can count on rides to and from chemotherapy, radiation or dialysis appointments. Sutter’s home health clinical staff can use Lyft to travel to and from consumers’ homes, rather than their personal vehicles, which they have found to improve workflow efficiencies allowing clinical staff to spend more time on skilled care and less on travel time.
A pilot collaboration between Virtua Health, a five-hospital health system, and Ride Health, a transportation coordination platform, resulted in 20% more inpatient bed availability. The cost per ride to transport discharged consumers also dropped by 50%. Based on the pilot outcomes, Virtua Health is now expanding the program systemwide to its outpatient-based provider organizations and to its newly acquired system hospitals. The Ride Health platform evaluates the consumer profile to automatically identify the right transportation provider, vehicle type, and service level for an individual, regardless of physical or psychosocial needs. The Virtua Health care coordinators enter consumer profiles into the Ride Health system. The profiles include demographic information, home and facility locations, accessibility needs, and communication preferences.
On March 3, 2020, the New Jersey Housing and Mortgage Finance Agency (NJHMFA) launched a new $50 million initiative to provide funding for 400 apartments for residents with special needs. The funding is through the Special Needs Housing Subsidy Loan Program (SNHSLP). NJHMFA will finance the new program through bonding and its own contributions. The state has begun to receive applications, and will continue to accept them as long as program funds are available. The application process is not competitive and is open to all eligible projects that meet the program criteria. For special needs-only developments, the maximum loan amount may not exceed $500,000. For multifamily projects, the maximum loan amount may not exceed $125,000 per unit, with a maximum of five units per project.
On February 6, 2020, the City of Los Angeles launched a pilot entrepreneurship program for people with insecure housing or who are homeless. The program, LA: EnterpRISE, will provide entrepreneurship and financial literacy training, as well as access to startup funding opportunities. During the first year about 200 people will be able to participate. Business startup assistance will be offered for any industry of interest to the participants. Participants will be referred by provider organizations serving homeless and at-risk individuals. The provider organizations will identify those seeking to launch a business and refer them to LA: EnterpRISE. Each participant will receive entrepreneurship training through workshops facilitated by the Mayor’s Office of Economic Development. Upon completion, participants will be referred to one of the city’s WorkSource Centers or BusinessSource Centers.
The health challenges of the justice-involved population in the corrections system are significant. This corrections population and the challenges in improving their health status and reducing unnecessary health care spending were the focus of a great discussion, Best Practices For Community Reintegration: From Custody Back To The Community, at The 2020 OPEN MINDS Management Best Practices Institute. The big takeaway? Successfully improving the health of justice-involved consumers involved building “bridges” to this consumer group —both reaching out to them when they are in correctional facilities and making outreach easier. The renewed attention to the health care needs of these millions of consumers presents an opportunity for entrepreneurial provider organizations. Some of the key capabilities that payers are looking for include capabilities for consumer outreach and engagement as well as 24/7 assessment and crisis services.” In addition, provider organizations should be prepared to help find employment and housing, get transportation, and coordinate primary care and behavioral health services.