Medicare Advantage Plans Covering More SDOH Benefits

Healthcare experts agree that nonmedical, social factors such as housing, nutrition, and access to recreation can play a significant role in shaping people’s health. With that being said, Medicare Advantage (MA) plans can now cover benefits that address some of these social determinants of health (SDoH).

But last year, a relatively low percentage of plans offered the benefits permitted by CMS to address SDoH. A Milliman report identified only 102 plans as offering new SDoH services, cost, funding, and novelty are some of the impediments. MA plans can use their rebate money-the difference between their estimated costs (and profit) and county-level financial benchmark-to pay for SDoH and other “supplemental” benefits for their members (the rebate money can also be used to lower cost sharing). However, according to an Urban Institute report, the average rebate in 2019 was $107 per member per month. That is not much money for tackling the complex, often deep-seated problems that come under the heading of SDoH.

Sean Creighton, a managing partner at Avalere Health, says MA plans are beginning to ramp up their SDoH-related coverage. Many are creating partnerships and referrals to community and other organizations. Examples include Humana’s Bold Goal program, a population health strategy focused on both community and business integration to improve the clinical and social health outcomes, and CVS Health’s Building Healthier Communities, a five-year, $100 million commitment that supports critical programs and partnerships with local and national nonprofit organizations.

More benefits allowed in 2020

Social determinants of health can be defined in many different ways. At a simple level, they can be thought of as almost anything nonmedical and nongenetic that has an influence on people’s health. Some definitions emphasis the notion of “place”-conditions in the environments where people are born, live, learn, work, and play. There are various estimates of the effects of SDoH; some say they account for 80% of people’s health status. But teasing out the effect of just one of them to focus may be difficult. In addition, the effects can be measured in myriad ways: quality of life, years of life lost, morbidity, mortality.

Related: Is Healthcare a Social or Medical Issue? SDoH Make it Both

Among the supplemental benefits that CMS allowed MA plans to offer last year were adult day care services, home-based palliative care, in-home support services, medically approved nonopioid pain management, transportation, and home and bathroom safety devices. This year, CMS added more to the list for MA beneficiaries with chronic disease, including an expansion of the meal delivery benefit, transportation for nonmedical needs like grocery shopping, and “home environment services” if they relate to the chronic illness. In a press release, CMS gave the example of a MA plan covering home air cleaners and carpet shampooing for someone with asthma because they could reduce irritants that would trigger an asthma attack.

So far, MA SDoH supplemental benefits have focused mainly on housing, nutrition, transportation, and social support, according to Creighton.

“The services are intended to assist beneficiaries maintain themselves in their homes (in home health services), access providers to stay healthy (transportation or telehealth), help people with functional limitations (home modifications) and address other daily needs (nutrition),” he says.

Wren Keber, managing partner at Cardinal Consulting Group, a Los Angeles healthcare consulting firm, says payers, providers, and public officials are all starting to realize the value that addressing SDoH carries in improving physical and mental health outcomes.

When researchers at NYU and Columbia searched LexisNexis and Google to find public announcements about health system SDoH programs in 2017, 2018, and most of 2019, they identified 78 unique programs involving about $2.5 billion in funds. Housing-focused programs accounted for $1.6 billion of the spending. They reported their results in the February 2020 issue of Heath Affairs.

The Urban Institute conducted 10 “semi-structured” interviews to prepare its September 2019 report titled, “Are Medicare Advantage Plans Using New Supplemental Benefit Flexibility to Address Enrollees’ Health-Related Social Needs?” The answer to that question is yes, but in a limited way. None of the insurers that the institute interviewed had extended coverage on nationwide basis. The new benefit flexibility was not accompanied by additional funding, the reported noted, and the interviewees mentioned that the availability of community organizations that can provide the services varies from area to area.

“For Medicare Advantage plans, rebate dollars fund supplemental benefits, so the idea is that SDoH services will fold into plan supplemental benefits for 2020,” says Keber. “There is an increasing body of evidence that managing social determinants of health for an at-risk or rising-risk population can result in improved quality and financial outcomes.”

Robert W. Seligson, executive vice president and CEO of North Carolina Medical Society, is among those spearheading the state’s efforts to address SDoH. North Carolina recognized the importance of SDoH impact early on and has embedded SDoH within the financial incentives and quality measures of its Medicaid program, he says. North Carolina’s Section 1115 Medicaid waiver allows the state to implement a five-year, $650 million pilot program that will test the impact of using Medicaid dollars to pay for evidence-based, nonmedical interventions related to housing, food, transportation, and interpersonal safety, Seligson explains.

“We are hoping to improve outcomes so others can recognize that SDoH are an important focus area that all healthcare stakeholders need to address to deliver high-quality care and maximizes resources,” he says.

By incorporating SDoH in payment and care delivery reform, physicians will be given the tools necessary to improve their patient’s health holistically while reducing costs and administrative burdens, says Seligson. Physicians are not SDoH neophytes; they have long recognized the impact of social and environmental conditions on patient outcomes, costs, and the physician-patient relationship. He points to a 2018 survey by the Physician Foundation of more than 8,500 physicians. Ninety percent reported that patients had a serious health problem linked to poverty or other social conditions.

Adding benefits is not enough

SDoH is certainly buzzy but quality and financial metrics haven’t caught up to the trend and are largely silent on the subject. For example, the metrics the CMS uses its Shared Savings Program, its largest ACO program, don’t use SDoH-related measures or adjustments.

“If we are to improve health and bend the cost curve, ‘social risk’ and SDoH must be accounted for in payment models and risk adjustment,” Seligson says.

As CMS updates existing payment models and develops new ones, it is essential that incentives to address SDoH are built into them, he argues.

Still, Theresa Hush, CEO of Roji Health Intelligence LLC in Chicago, sees the inclusion of SDoH-related benefits for Medicare Advantage plans as a critical first step for deepening services for vulnerable individuals, especially the many beneficiaries with dual eligibility in Medicare and Medicaid.

“Since MA plans typically attract healthier and younger beneficiaries, the specific provision of SDoH should enable plans to broaden coverage within the Medicare population,” she says.

But just adding benefits is not enough, asserts Hush, who noted that accurately assessing patient needs is difficult. Add to that network and interventions needed to address those needs.

Hush says providers under contract with MA plans will need financial and other support, such as with analytics and data tools.

“Plans must measure and assess individuals’ needs better and standardize quality and outcome measures, data capture, and risk assessments,” says Hush.

She sees an opportunity for MA plans and providers collaborating to achieve lower costs and better outcomes.

Creighton at Avalere suggests a pick-your-battles approach.

“One challenge is narrowing down actionable items for a health organization,” he says. “Healthcare organizations’ impact on communities can be huge, but organizations must decide where to direct their resource.”

But he also sees an opportunity for larger health systems’ potential impact on communities to extend well past patient outcomes to employment, improved income, and possibly even environmental improvements to their communities.

But there’s also a need for better data collection to identify and prioritize, on a micro level, people’s greatest need, Creighton says. “It’s a huge issue because while there is data that will tell you about the relative advantage or disadvantage of particular communities, we need to get down to a very local level to figure out who needs something done to improve their health.” Right now, plans are offering what Creighton calls a “smorgasbord of approaches and ideas.”

“The aim is to get to a certain nexus between our day-to-day social and economic life and our health by integrating aspects of the healthcare system with the social and community services delivery systems,” he says. “And there are a lot of different initiatives going on to do so.”

Creighton see progress in the growing number of programs in the “food category” of meals and wellness and housing. In new ways and with different purposes, the SDoH surge is bringing back the house call.

“If you look at the social support aspect of this, there’s also been a big increase in the provision of in-home services which get at social support and other aspects of social determinants,” says Creighton.

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.