Lessons from Medicaid on Social Determinants of Health Innovation

Strengths of Medicaid’s SDOH approach

The overarching theme of the report is that Medicaid programs, broadly, pursued social determinants of health as a key aim.

“What our report found, that was somewhat surprising for us, was the extent to which this had really become common place,” Newman told HealthPayerIntelligence. “It's now really the consensus that addressing social determinants of health is critical to the health and well being of vulnerable populations. And we only expect this trend to accelerate.”

Most state Medicaid programs and their Medicaid managed care organizations integrated social determinants of health strategies into their care management, with 27 states screening for social determinants, 37 states coordinating social services for beneficiaries, and 35 states referring to social services.

“What we know is that there's already a lot of great experimentation and innovation going on right now by health plans and payers,” said Newman. “And there are a lot of opportunities to learn from what others are doing. The evidence-base is only going to get stronger. So health plans will be able to refine their strategies to ensure they're deploying things that are effective.”

However, Medicaid programs do not have the resources or intimate knowledge of region-specific needs to singlehandedly support beneficiaries’ various social needs.

As Caraline Coats, vice president of Bold Goal and population health strategy at Humana, noted in a recent Healthcare Strategies episode, it would be a mistake to discuss whole person care without mentioning that payers need to increasingly bring community-based organizations to the table for conversations about social determinants.

Medicaid programs proved well aware of this interdependency and the relationships between programs and community-based organizations have adapted to better accommodate that reality. Nearly half of all states (23 states) partnered with community-based organizations to meet beneficiary social determinants of health needs.

“Another thing that's quite clear from our research and the report is that addressing social needs is not the health plans responsibility alone. These are really complex issues and they require multi-sector solutions and partnerships,” said Newman.

“Addressing unmet social needs requires a multi-sector approach. And we're definitely seeing in the contract language between States and their health plans requirements emerge that the health plans partner with community-based organizations.”

As these relationships solidify, a middleman has also started emerging, the report found. Intermediaries that represent community-based organizations have started to take shape to form referral networks between organizations and coordinate efforts in a given region.

Some states established social determinants of health departments to give these barriers focused attention.

Areas for improvement, emerging strategies in Medicaid’s SDOH approach

Twin, perennial issues plague Medicaid’s approach to social determinants of health: sustainability and data.

“On the sustainability side, I think that it's going to require a multi-pronged solution,” said Dutton. “We can't expect healthcare providers or health plans to create a social safety net where inadequacies exist. So whatever solutions happen through the healthcare sector to address social determinants are going to be partial solutions. But what we are seeing is we're getting smarter about where those interventions are effective and most impactful.”

Dutton also noted that the two issues are conjoined. Before Medicaid programs can enhance the sustainability of their social determinants of health programs, they need data to guide their efforts.

“There's still a lot of room for experimentation and learning in terms of how we create sustainable investments in social determinants to improve health outcomes and efficiency,” said Dutton. “We can't do that without access to information, both in real-time that enables us to manage individual patient care, but also retrospectively from an evaluation perspective that enables us to aggregate that information and pull trends and broader scale learning from that information.”

Data exchange platforms have started becoming more popular among health plans and community-based organizations in order to support their burgeoning relationship.

“An interesting trend we've been seeing on the issue of data sharing and bridging the gap across the various sectors that serve patients or members, is the emergence of platforms to be able to communicate,” Newman noted.

“There needs to be some accountability mechanism to understand the extent to which plans are indeed helping their members access those resources. And to be able to have that accountability, you need data. Right now, the data systems are lagging it, but we are seeing some States experiment on that.”

How health plans can apply this data

Newman had three recommendations for health plans based on the data from the report.

First, they can continue to innovate solutions to social determinants of health barriers. Testing, designing, and developing programs and benefits that target these needs is a crucial role that payers play in reducing social determinants of health.

Second, payers can build the network of resources and partners that fill in the gaps on their social determinants of health approach.

“As I mentioned, it's not something that health plans can do in isolation,” Newman said. “It really requires a partnership approach that will position them well to address the needs of their most vulnerable populations.”

Third, health plans can work closely with their communities. For example, Blue Cross and Blue Shield of Kansas City has noted that their closeness to the region and long-standing relationships with community-based organizations have been an advantage in addressing social determinants of health and establishing a referral network.

“To the extent that plans can engage with and involve their communities in determining which areas of social determinants of health to focus on and in the program design, that will serve them well also,” Newman added.

Future trends, survey limitations

Dutton and Newman foresaw this trend of greater emphasis on social determinants of health building in the future.

“What we're hearing from the States as we've been pulling this information together is that they expect it to accelerate in the year ahead,” said Dutton.

“It's both being driven by COVID, but also by States moving to more value-based payment arrangements within their Medicaid programs more broadly. And so, we're looking at this as a point in time, it's really informative, but we expected it to be dynamic in the year ahead, in there to be continued growth in the requirements that States are putting on Medicaid managed care plans related to social determinants interventions.”

The survey exhibited a couple of limitations.

Namely, there were social determinants of health initiatives not represented in this data because they fell under COVID-19 response waivers, not Medicaid managed care contracts or section 1115 demonstration waivers.

Also, systemic racism, which can result in health disparities, is increasingly recognized as a social determinant of health, but they also require interventions outside of health. This report only analyzed health equity related to social determinants of health.

Finally, the researchers acknowledged that there was room for large changes occurring after the survey period, in part due to the election and protests.