Overcoming Challenges to Medicaid Investments in Social Determinants of Health

Martinez-Vidal E, Chang D, McGinnis T
Publication Year: 2018
Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Population Focus: Medicaid beneficiaries
Demographic Group: Child
Intervention Type: Partnership, Staff design and care management
Type of Literature: Grey


Insights Results

Overview of article

  • AcademyHealth partnered with the Nemours Children’s Health System to work with Maryland, Oregon, and Washington State to explore current Medicaid authorities to promote and provide prevention services in community settings, cover upstream prevention benefits such as assessing a home for asthma triggers, and deliver services using nontraditional community-based providers. The team identified several practical lessons and approaches that state Medicaid agencies, health plans, providers, and other stakeholders can use to overcome the challenges to investing in efforts that address social determinants of health under Medicaid

Key takeaways/implications

  • This study highlights a report that found private and public payers in Washington State would see $343 million in annual savings by collectively investing $10 per person per year in community-based disease prevention programs. This finding suggests investing in chronic disease prevention projects for asthma, obesity, diabetes, and heart disease. Examining options under the state’s Medicaid Transformation demonstration, Healthier Washington, it became clear that accountable communities for health could reap economic rewards by using delivery system reform incentive payments under Section 1115 demonstrations to invest in prevention and health promotion for Medicaid beneficiaries
  • In addition, several state Medicaid agencies are pursuing cost-effective strategies to address social determinants of health. States can make the case for managed care organizations (MCOs) to address social determinants of health by leveraging authorities for both community care coordination and value-added services, which are services that are outside of the Medicaid benefit package but that seek to improve quality and health outcomes and/or reduce costs (that is, asthma trigger home assessment or mosquito repellant to prevent Zika). For example, Oregon requires each coordinated care organization (CCO) to develop a specific plan and associated processes for identifying patients whose health would benefit from a value-added service, such as a nutrition class. After delivering that service, the CCO must report to the state which services were delivered. New Mexico incorporates the cost of community health workers into the administrative portion of its MCO and requires MCOs to increase community health worker contacts with enrollees by 10% in both 2017 and 2018
  • 2 commonly used approaches to address the social determinants of health include community health workers and community care coordination systems. There is ample evidence demonstrating community health workers’ capacity to improve outcomes for individuals with chronic conditions, including asthma, diabetes, and heart disease, and community health workers are employed in all 50 states. For example, Washington State’s Medicaid agency leverages staff capacity already available within MCOs to provide community health worker services. Known as community connectors, these individuals are members of their communities who connect clients to MCO care managers and available social services
  • Lastly, this article suggests Medicaid partner with local state agencies and other community-based organizations at the local level. For example, with the understanding that Medicaid cannot adequately address and invest in these social determinants on its own, Head Start is one natural partner offering significant opportunity for alignment of care coordination and service delivery with Medicaid. Building on work in Maryland, this article explored connecting Medicaid MCOs with local Head Start programs to better link children and their families to needed services—including upstream preventive services. Maryland is embarking on a childhood obesity prevention pilot to provide nutritional counseling in Head Start settings by a licensed dietitian
  • Across efforts examined in this article, the following factors were identified as accelerators to drive state action: 1) Allow flexibility on how to accomplish goals based on stakeholder input; 2) Employ strategies that link traditional clinical care with community-based prevention initiatives; 3) Focus intervention on the family as the unit of partnership; and 4) Think broadly about ways to use payment reform, instead of only addressing a specific issue because patient needs and community resources will vary greatly so a broader approach that has built-in flexibility and adaptation will enable local stakeholders to develop tailored solutions. Oregon, for example, provides its CCOs with a global budget for which they have flexibility to address specific community health needs and are incentivized to address social determinants of health