There is a lot of talk about how social factors affect health care costs, but not a lot of action. We’ve covered the recent developments—from the emerging data that reinforces the importance of addressing social determinants of health (see Social Determinants—The Next Frontier and What Are The Social Determinants Of Health?), to the initial steps health plans are taking to fund social support services (see What Are Payers, Health Plans, & ACOs Doing About Social Determinants? and Payers Approaches To Addressing Social Determinants Vary).
The biggest impediment to payers and provider organizations taking action on social determinants of health has been payer policy. The Centers for Medicare & Medicaid Services (CMS) has been very specific that Medicare and Medicaid plans cannot pay for non-medical benefits (see Leveraging Medicaid To Address The Housing Issue and For Supportive Housing, Creativity Required). However, a few states are attempting to address social determinants in their Medicaid plans (see CMS Approves North Carolina’s 1115 Medicaid Managed Care Waiver, Ending The Behavioral Health Carve-Out and CMS Approval Of California Medicaid State Plan Amendment For Non-Medical Transportation)—but the details of these plans are still in the works.
That is why recent legislative changes in the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 matter (CHRONIC was part of the Bipartisan Budget Act of 2018, signed into law on February 9, 2018). Starting in 2020, Medicare Advantage plans will be able to offer enrollees expanded non-medical supplemental benefits, such as transportation or nutrition for individuals with complex health and social care needs (see Medicare Advantage Plans Approved To Offer Expanded Non-Medical Supplemental Benefits). And, in 2019, CMS will expand its definition of “primarily health-related” to consider an item or service as primarily health related if it is used to diagnose, compensate for physical impairments, acts to ameliorate the functional/psychological impact of injuries or health conditions, or reduces avoidable emergency and health care utilization. Examples include adult day care services; home-based palliative care; in-home support services; support for caregivers of enrollees; medically-approved non-opioid pain management; stand-alone memory fitness benefit; home and bathroom safety devices and modifications; transportation; and over-the-counter benefits.
For more on what this could mean, we reached out to OPEN MINDS senior associate and former chief operating officer for Pittsburgh Mercy Health System, Ray Wolfe, who noted:
It’s such a small change in the Medicare Advantage rules for 2019, but it’s a landmark moment for health and human service provider organizations that regularly integrate social determinants of health into their service. For the first time, issues such as nutrition, housing, and transportation can be addressed through Medicare Advantage plans and paid just like lab tests and pharmacies.
Technically, the wording, “primarily health-related”, now includes services that “have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee.” The average person would be hard pressed to explain the differences or why items improving health were not previously considered health related, however, for many with chronic conditions who will benefit from this, the change may be striking.
Mr. Wolfe went on to explain that this change is occurring because there is a growing universal acceptance that social issues influence health and wellness, and that addressing them will save health care costs in the long term. How the U.S. health and human service system will operationalize solutions to “whole person health” that includes the environmental, lifestyle, and social factors is not yet clear, but these seems to be a step in the right direction. The Annual Industry Pulse Survey showed 80% of payers believe addressing SDH are important, 42% are integrating SDH programs into their population health efforts, and 34% are using census and socioeconomic data to augment their clinical data (see The Possible Dark Side Of Social Determinants Of Health). The added possibility that these services can be paid for will only increase the rate that health plans adopt these approaches (see What Are Payers, Health Plans, & ACOs Doing About Social Determinants?). Mr. Wolfe explained how important this conversation is to prepare for, noting:
Health and human service provider organization executives should start now to have conversations with health plan managers about their consumer outcomes and spending that are most affected by social factors—and about developing innovative integrated care coordination programs that include addressing social services. These new programs need to be developed with the ability to demonstrate return on investment for health plans. New opportunities could include transportation initiatives, prevention programming and nutrition training, medication compliance programs, and respite programming to reduce hospital stays made excessively long by societal and not medical reasons. As the distinction between health and health related services dissolves, this may become an exciting new growth area.
For more great reading to help your team get ready to develop new programming integrating social services, check out these resources from the OPEN MINDS Industry 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
Also, be sure to join OPEN MINDS Senior Associate and Former SVP Network Strategy, UnitedHealth Group/Optum Deb Adler at The 2019 OPEN MINDS Performance Management Institute on February 13 for “The OPEN MINDS Health Plan Partnership Summit: A Guide To Developing & Negotiating Partnership Agreements With Health Plans.”