Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care

Daniel-Robinson L, Moore J
Publication Year: 2019
Patient Need Addressed: Financial insecurity, Food insecurity, Homelessness/housing, Long-term services and supports, Transportation
Population Focus: Medicaid beneficiaries
Type of Literature: Grey

The Medicaid program provides healthcare coverage to more than 70 million Americans who are most vulnerable to the negative effects of unmet social needs. An important opportunity exists within the Medicaid program to identify and address the unmet social needs and risk factors that have a significant impact on health outcomes and costs. With access to enrollee health data, Medicaid managed care organizations (MMCOs), with the support of state Medicaid agencies and community-based organizations (CBOs), are well positioned to coordinate both the health and social components of care that will have the most influence on the outcomes of individual enrollees (and families). However, better coordination, supported by state policy and financial mechanisms, might be needed to improve MMCOs’ capacity to fulfill this opportunity. The extent to which the Medicaid program can successfully address the social determinants of health could have a substantial impact on population health

Insights Results

Overview of article

  • A range of other factors, collectively categorized as social determinants of health (SDOH), have a more profound influence on care, outcomes, and population health
  • Federal and state policies, along with the health system and market, have driven improvement in costs and population health outcomes. For example: 1) The Medicaid home and community-based services (HCBS) program provides a mechanism to address the long-term services and supports (LTSS) for individuals with specialized healthcare needs in noninstitutional settings. Although the HCBS program targets specific populations based on diagnoses, the program components provide a model for considering the social determinants of health more broadly for the Medicaid population; 2) The Section 1115 waiver authority is a long-standing mechanism to provide states with the flexibility to conduct pilots and demonstration projects tailored to optimize the delivery of care within the state. Delivery System Reform Incentive Payment (DSRIP) programs, authorized under Section 1115 authority, provide a mechanism for state Medicaid agencies to innovate care delivery and payment linked to demonstrable improvements in health outcome metrics; and 3) To support the implementation of the accountable care communities, the CMS developed the Accountable Health Communities Core Health-Related Social Needs (AHC-HRSN) screening tool to assess five critical areas of SDOH—transportation, housing instability, utility assistance, food insecurity, and interpersonal safety. As of September 2018, there were 31 organizations implementing an AHC model; with all of the models implementing a variety of approaches that center on the five critically defined areas
  • Barriers in addressing SDOH in Medicaid emerge from challenges in coordination, data sharing, and financing. For example, silos between social services, health organizations, and providers prevent the robust exchange of information and data about available services, unmet needs, and costs. In addition, leveraging community-based organizations or other non-traditional partners to address SDOH may be further impeded by more general programmatic funding constraints. Although Medicaid MCOs continue to invest in programs, a documented return on investment (ROI) might not be evident for some interventions

Key takeaways/implications

  • There are opportunities to address social needs through systematic and continuous collection and exchange of data. This is possible through the electronic data interchange (EDI) 834 enrollment form or EHRs. This data should be used to develop profiles containing social-need information that can be used across all clinical sites
  • Several states have initiatives that address social needs in Medicaid: 1) The North Carolina Department of Health and Human Services is leading comprehensive health system reform that supports population health management through the shift from Medicaid fee-for-service to managed care. As part of the shift, care management in the state will provide Medicaid enrollees with access to programs and services that address their social needs; and 2) Washington, DC formed a coalition known as D.C. Positive Accountable Community Transformation (PACT), aligned itself as a combination of 2 models – accountable health community and collective impact
  • Areas for future research: Further exploration is needed into models that address how information is collected, stored, shared, and used to help address the needs of vulnerable individuals. A range of clinical, research, and policy priorities may be considered to move towards a system that better integrates healthcare treatment with social interventions as applicable. Specifically, clinical priorities should focus on standardizing social determinants of health information, exploring alternative care delivery approaches, and identifying strategies to target at-risk populations. Research priorities should focus on identifying sustainable funding sources to address social determinants of health and determining the valuation of social intervention strategies. Lastly, policy and advocacy priorities should focus on establishing an evidence-based, nationally standardized screening tool/quality metric, identifying strategies to fund social interventions that have an impact on health outcomes, and supporting multi-stakeholder engagement to successfully integrate social interventions strategies