4 SDOH Barriers Payers Can Address to Drive Access to Care

Access to behavioral and mental healthcare services

Since mental and behavioral healthcare tend to snowball, payers can prevent a broad spectrum of serious conditions by providing members with access to behavioral and mental healthcare services.

Patients in need of behavioral and mental healthcare services are often forced to use out-of-network providers and specialists to meet their needs, which means skyrocketing out-of-pocket healthcare spending. 

From 2013 to 2017, the likelihood that a patient would resort to an out-of-network inpatient facility for their behavioral and mental healthcare rose 85 percent. Experts have emphasized that payers and employers are the only ones who can fix this problem, leading to savings on healthcare spending as well as better patient outcomes.

The shortage of providers is genuine, however. Telehealth programs have become a common answer for many payers, including Cigna.

Cigna has partnered with MDLIVE to provide its members with a guided search tool that directs them to the best behavioral or mental healthcare provider to assist them through a virtual appointment.

The payer leans on its network of over 15,000 providers to help patients get access to care.

After the platform connects patients with the right providers, it is up to the patient to decide whether they would prefer a virtual or in-person appointment.

The platform reduces the fatigue of trying to find a provider, complexity and length of time it takes to nail down an appointment time, and the discomfort or stigma of going to a public place for the appointment.

The payer works with employers to spread the word about this tool.

Social determinants of health barriers for behavioral and mental healthcare are among the most untouched of these four barriers. 

Access to mental healthcare may also be one of the most serious of the four due to its widespread nature and detrimental effects. The results of leaving this social determinant of health untouched have manifested in the national mortality rate, which is being boosted by behavioral and mental conditions.

Transportation to healthcare sites and healthy activities

According to the American Health Association, 3.6 million people in America do not receive healthcare because they do not have access to transportation. Whether that is due to not owning a vehicle, the time it takes to reach health activities and services, or any of a myriad of other restrictions, transportation tends to get in the way.

Payers have widespread recognition of the need for access to non-emergency medical transportation (NEMT), but adoption has not necessarily been whole-hearted due to logistical and cost concerns. 

Transportation benefits are particularly targeted to the senior population to promote an active, social, and healthy lifestyle. 

An Urban Institute study interviewed five Medicare Advantage insurers, together representing 38 percent of the market, and found that all of the payers had an NEMT benefit before the 2019 CMS social determinants of health guidance.

But one of the five plans expressed hesitancy from further expanding the benefit because it was concerned that members might use up their limited number of rides for non-emergency reasons and then have no coverage to take transportation to see the provider.

Some payers, such as Alignment Healthcare, have offered NEMT assistance through a third-party rideshare, instead of by providing access to healthcare transportation vehicles.

Alignment Health started its access to care program, ACCESS On-Demand Concierge, and partnered with Uber Health to make transportation affordable and easy to obtain for Medicare members. At any time on any day, members can use Uber to arrange for covered transportation to non-emergency, healthy activities.

Many members had already used the tool before and so were able to quickly adapt to it.

The payer repeatedly reminded customers that the rideshare option is for non-emergency situations only. It aimed to reduce expensive emergency visits by offering transportation to alternative sites of care. The payer evaluates its member satisfaction reports as a metric for success.

Cost-accessible drug pricing

The escalation in drug pricing can overturn medication adherence and worsen patient outcomes.

CMS recently proposed a new rule for Medicare Advantage plans which would promote generics and biosimilars in order to lower overall healthcare spending. 

Generics were designed to be the lower cost replica of brand-name drugs, but in some cases they have proven to be more costly than their doppelgängers—specifically for Medicare beneficiaries.

Eighteen Blue Cross Blue Shield Association companies are working to diminish the cost of generics. Banding together, they have partnered with a non-profit generic pharmaceutical manufacturer to compete with other generics manufacturers.

By producing more generics, the companies seek to heighten the competition, lower costs, and raise their members’ ability to afford medications.

“We believe everyone should have access to health care, no matter who they are or where they live,” said Scott P. Serota, president and chief executive officer of BCBSA. 

“Through this partnership, we will push toward the vital objective of providing greater access to much-needed medications.  As BCBS companies and Civica embark on this important work, we hope others will join us to achieve the change Americans want to see in the health care system.”

In 2019, a Blue Cross Blue Shield Association company also shrunk access to affordable medications barriers by instituting a $0 copay on insulin. The move made chronic disease management more accessible for members with diabetes.

Physical and virtual medical care

Perhaps the most obvious, if highly resource intensive, way to increase access to care is to establish clinics in unreached areas.

Just recently, Humana announced that it would be more than doubling the number of Partners in Primary Care centers for seniors on Medicare Advantage from 47 to 97. Each center could draw anywhere from 1,500 to 2,500 risk members who would otherwise struggle to obtain access to care.

The centers will be entrenched in Humana’s value-based care model and will aim to simplify patient experiences and leverage its own primary care services as well as its partnership network to achieve integrated care.

For payers that cannot finance more physical care locations, virtual care “sites” serve a similar purpose and may be a worthwhile investment.

Tufts Health Plan recently chose to invest in a telehealth virtual care solution, an app called Teladoc. While some virtual care sites focus on a particular medical need, Tufts Health Plan’s site can diagnose and recommend treatment for general medical concerns anywhere in the world—from allergies to the flu, and more.

“For members seeking more convenient and immediate access to medical care, we are removing all of the barriers to assure our members seek and receive care when they need it,”  said Jim Gallagher, vice president of marketing and product strategy for commercial products at Tufts Health Plan. "This market-leading benefit is part of our overall goal to create a world class experience for our members with innovative digital tools and services.”

Starting a virtual care platform is not simple. On episode 6 of Xtelligent Healthcare Media’s Healthcare Strategies podcast, Amy Lerman from Epstein Becker Green talked about how to launch virtual care platforms, specifically ones intended to meet mental and behavioral healthcare needs. One practical insight she offered, for example, was to ensure that the platform has a network of providers that are licensed to cover members from every potential geographic location in which the service will be available.

By targeting these four social determinants of health barriers, payers can enable greater access to care for their members—which is exactly what healthcare coverage is designed to accomplish.