How Technology Infrastructure Will Help Social Care Providers Transition to Value-Based Payment

Health care is a term often associated with doctors, hospitals, and medical treatments. Indeed, dictionary definitions of the term often invoke medical interventions as examples of health care services. Yet the importance of social factors in the health of an individual or community can no longer be ignored. We, therefore, offer a clarified definition of health care to include the sum of three categories of service providers:

• Medical Care Services (care management, physicians, hospitals, etc.)

• Behavioral Health Care Services (psychologists, social workers, substance use treatment providers, etc.)

• Social Care Services (housing providers, food assistance providers, transportation assistance providers, etc.)

The evolving health landscape

Social care providers, sometimes referred to as community-based organizations, are on the cusp of a disruptive change in the way they can operate financially. The old system of attaining funding by requesting grant money from the government or private foundations is rapidly being replaced by a move to receiving funding from health insurance companies and at-risk care delivery organizations who offer financial incentives-such as shared savings-for their part in keeping individuals healthier while reducing the total cost of care. 

This is all part of a shift in the focus of health care overall. In the past, medical care providers were paid based on fee-for-service (FFS) arrangements. As such, the services they delivered were completely independent of services delivered by social care providers. 

Today, health care payment policies are moving toward value-based models, where provider reimbursement from health insurance companies is based on improved health outcomes rather than volume of services provided. The healthier they keep their patients-and the more they can prevent them from needing the hospital or emergency department-the more money they make. Needless to say, this is a 180-degree turnaround, and it hasn’t been painless. Since reimbursement is tied to health outcomes, the spotlight is shining brighter on the social care providers to which they refer their patients.

Related article: How Technology is Addressing SDOH

Medical care providers can no longer simply refer an individual to a social care provider and consider their part finished. Both sides need to work together to track referrals and report on outcomes, preferably as part of an organized network, so they can both reap the rewards of the risk-based contracts. Some examples of states, managed care organizations (MCOs), and social care providers that already have programs under way include:

• Arizona, which requires coordination of community resources such as housing and utility assistance under its managed long-term services and supports contract.

• The District of Columbia, which encourages MCOs to refer beneficiaries with three or more chronic conditions to the “My Health GPS” Home Health program. 

• Louisiana, where plans are required to screen for problem gaming and tobacco use, and referrals to the Special Supplemental Nutrition Program for Women, Infants, and Children are required.

• Nebraska, which requires MCOs to have staff trained on social determinants of health (SDoH) and to be familiar with community resources.

• North Carolina, which has established NCCARE360, a state-wide closed-loop referral network between social care providers, MCOs, and medical care providers.

Health payers have also taken an active interest in this new, integrated approach as evidenced by the announcement that Kaiser Permanente has launched a program to equip all of the providers in its network with technology tools to address SDoH. Working with Unite Us, a health IT network that links social care organizations with medical providers, Kaiser Permanente is looking to create a seamless electronic platform for supporting connections between organizations. This concept was pioneered by Unite Us in partnership with Alliance for Better Health, which was a significant contributor to its SDoH model.

To survive and thrive in this new value-based world, social care providers will need to partner much more closely with medical care providers and demonstrate not only the activities they’ve undertaken but also the results they’ve achieved. Yet that can be difficult when their organizations aren’t traditionally set up to make referrals to each other or to track and report on shared activities such as assisting an individual in a truly collaborative manner. 

Helping to bridge that gap is a new generation of technology designed specifically to connect medical and social care providers together around the individual. It creates a platform both sides can use to track and manage referrals and referral outcomes electronically, eliminating the need for endless faxes and spreadsheets that never seem to be updated in a timely manner. It also makes it easier for social care providers to track and report the outcomes of their interventions in real time, demonstrating how they are keeping individuals healthier and reducing costs so they can more easily reap the benefits of value-based shared savings. 

Making the connections

Both insurance companies and medical care providers have become far more aware of the effects social factors have on the health of individuals, families, and communities. As a result, many are actively building or looking for existing networks of social care providers to which they can refer individuals.  

All too often, however, this action amounts to simply handing individuals a piece of paper or sending them to a website that lists local social care providers in various categories-perhaps making an introductory phone call or sending a fax. After that, the referral is out of the payer’s or provider’s hands, which means they may not even know if the individual has sought out the help they suggested. 

As a result, there often isn’t much discussion or collaboration between members of the medical care team and social care providers, or even between two social care organizations. Health plans and providers gain little sense of which social care providers are doing the best job of connecting with individuals and getting them the results they seek. 

Related: How Does Chronic Illness Affect SDOH Perceptions?

A scalable technology platform that has been proven useful by both medical and social care providers makes it easy to establish-and maintain-lines of communication between health plans/health care organizations and social care providers. With the click of a button, health plans/providers can make direct electronic referrals, instantly see whether individuals enroll with the social care provider, and track the specific outcome achieved at that organization. The social care provider can also easily measure which health plans and/or medical care providers are delivering the most referrals so they can intensify their partnership efforts with them. 

Referrals are a two-way street, however, so the platform also makes it easy for social care providers to refer their individuals to primary care, or a particular hospital or health system. This is important not just for the sake of the individual's health, but also for taking advantage of value-based payments. 

In order to reap the financial rewards, social care providers must first be in the game. The more they can build strong referral networks with health plans and medical care providers, the more opportunities they will have to earn the trust of those organizations. 

Once they earn that trust, health plans and providers will likely find additional ways for social care providers to help them, such as contacting Medicaid to get an individual who has lost his/her eligibility reinstated or helping them close care gaps by arranging transportation to a laboratory for a required test. Then it comes down to performance. 

Becoming results-oriented

Social care providers have always focused on delivering the services their individuals need to better their lives. The strength of these organizations has been their singular dedication to making things happen. What most have not been asked to do, or have even needed to do, is quantify outcomes and align their performance in a meaningful way to medical care outcomes. With payment shifting to value, however, they no longer have that luxury. The core of value-based care and reimbursement is the ability to demonstrate that a particular intervention had an impact on the overall health of an individual, and of course, the quality and cost of care. 

Take the example above of the individual whose Medicaid eligibility is deactivated. Without it, their only option for care is the emergency department (ED), which they will start to visit more often in the face of any medical issue-even for something as trivial as a cold. 

By getting the individual reinstated, the social care provider ensures that the individual once again has access to primary care and any medications needed, which means visits to the ED are either eliminated or at least greatly reduced. There is not only a health benefit but a financial benefit to this that can be easily calculated as the reduction in the number of ED visits per month multiplied by the predicted cost of an ED visit. Being able to track and report on this change means the social care provider may reap a portion of the shared savings. 

Related article: 4 Ways Health Plans and Communities Can Address SDOH

Using a proven technology platform that places social care on the same plane as medical care gives social care providers a simple yet reliable way to report on the outcomes they’re helping generate, whether it’s ensuring an individual with behavioral health issues is taking his/her medications as prescribed, an individual with transportation challenges is keeping all of his/her health care provider appointments, or an individual with food security challenges is receiving a weekly delivery of healthy food choices and using them. 

Each of these activities-and many others-have a direct impact on health outcomes. Now, social care providers have a convenient, evidence-based means of reporting on them so they can demonstrate their value and potentially gain more funding than they ever could have in the grant system. Additionally, health plans and medical care providers can run reports to see which social care providers are delivering the best performance and outcomes so they can direct more of their patients to those organizations, rewarding excellence in a way that has never been possible before. 

Change for the better

Most organizations (and people) don’t like change and are often resistant to it. A framework such as the one we describe is ideally a shared, horizontally integrated, community-wide resource. Like street lights and telephone wires, it’s not a competitive advantage for one health system, health plan, or physician practice. In this model, moving toward value-based care holds the potential for social care providers to benefit tremendously so they can offer more and better services to more of the people who need them. 

The even better news is that they don’t have to figure out how to manage it on their own. By taking advantage of these new technology platforms and the underlying services they offer, social care providers can exponentially, and almost instantly, improve their ability to send and receive referrals as well as track and report on the results they’re achieving-creating a win-win for all involved. 

Next steps: The road to value

Through the lens of supply chain management, the technology connecting organizations across the continuum becomes the required foundational layer that’s creating the means to drive payment models between medical care providers and social care providers. This same technology layer allows for the measurement of the progress, performance, and outcomes delivered by all parties involved in a fully accountable network.

Now that we have these networks established, a service that sits between the payer or at-risk providers and social care providers can be implemented to manage the standardized payment mechanisms that allow the performing social care providers to continually grow their impact, sustainability, and performance. Since the technology mandates standards of performance, standards of information capture, and standards of process, it becomes easy to measure costs, performance, and outcomes in a transparent manner; we’re now able to use these standards to deliver value-based payment at scale: making the right thing to do for the individual the easy thing to do for the community.

This new service not only manages the payment, but also the quality reporting, contracting, cost accounting, operational tools and systems, and performance management needed to standardize integrated medical and social care delivery across communities.

In the end, this is a win-win for all parties. The medical care community cannot take on this endeavor alone. We need social care providers to provide quality social care, the technology to support the connections and track the outcomes, and the new intermediary service to allow the seamless business and operational framework enabling these two industries to integrate to improve health care as a whole.

Dan Brillman, is CEO of Unite Us. Jacob Reider MD, FAAFP is CEO of Alliance for Better Health.