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Social Determinants of Health, Value-Based Care Key for Medicaid Success

Policymakers should increase healthcare access and offer value-based care incentives to help state Medicaid programs address the social determinants of health.

Social determinants of health, value-based care key for medicaid success

Source: Thinkstock

By Jessica Kent

Value-based care incentives and broader collaborations to address the social determinants of health will be required to reduce spending and improve outcomes for Medicaid beneficiaries, according to a report from the Association for Community Affiliated Plans (ACAP) and the Center for Health Care Strategies (CHCS).

The report searched for common themes across Medicaid managed care contracts in 40 states to better understand how states are working to address the social determinants of health.

“Over the last 10 years, social determinants have moved from a novelty to an integral policy lever for states,” said Tricia McGinnis, MPP, MPH, Senior Vice President, CHCS.

“The report’s state-by-state comparison shows that states are taking myriad approaches to addressing social determinants. What’s really exciting is taking an inventory of these efforts from across the country — and identifying the key trends, including emerging areas of innovation.”

The report found that while many states set goals for social determinants in contracts, few offer payment incentives to support actions that may improve outcomes.

Additionally, while it is common for state contracts with Medicaid managed care organizations to include provisions around social determinants, many states do not clarify how managed care organizations can use flexibilities in federal law to address patients’ socioeconomic needs.

To further advance social determinants of health work, and to improve health outcomes, CHCS recommended that CMS and other federal policymakers focus their efforts in the following areas.

Increase access to healthcare and care coordination

In order for community-based population health management strategies to be effective, healthcare organizations must engage members for an extended period of time, the report said. In keeping with this concept, many states have built a specialized workforce for care coordination and have introduced holistic approaches to care.

To enhance these initiatives, the organizations recommend that CMS review state pilot projects that may limit individuals’ access to, and eligibility for, healthcare and coverage.

“These policies can exacerbate existing issues in Medicaid programs such as eligibility churn and member engagement,” the report stated.

“To the extent that CMS is committed to approving community engagement demonstration projects, CMS could consider the important role managed care organizations can play in helping members maintain their eligibility and satisfy community engagement requirements.”

Enhance federal collaborations

To address social determinants such as food insecurity and housing instability, ACAP and CHCS advised that state government agencies increase collaboration efforts. Working to establish more partnerships among health and social programs will further enhance social determinants of health work.

“Federal agencies could continue to collaborate on ways to coordinate federal health and social programs, prioritizing easier navigation for beneficiaries,” the organizations suggested.

“Targeted partnerships and cross-agency councils, such as the United States Interagency Council on Homelessness, can make collaboration on social determinants of health more commonplace.”

Offer additional guidance on how to increase social determinants investment

If CMS offered more guidance on how states can address the social determinants of health through their Medicaid managed care programs and value-based payment initiatives, states may be more inclined to build upon these strategies in their projects and contracts, the report asserted.

“Sometimes, states and managed care organizations just need a roadmap— an assurance that CMS will be receptive to their more innovative proposals,” the organizations wrote.

CMS should publish specific guidance on social determinants services that are offered as a substitute for, and not in addition to, a covered service, the report noted. CMS should also clarify that services that do not qualify as substitute services can still be value-added services.

Additionally, ACAP and CHCS recommended that CMS offer guidance on how Quality Assurance and Performance Improvement can be used to develop an evidence base for a particular social determinants of health intervention.

“Explanation of how states are authorized to use the Quality Assurance and Performance Improvement process to address members’ social determinants of health would encourage innovation at the state and plan level to develop interventions,” the entities said.

Approve state projects that test social determinants strategies

While CMS has approved many state demonstrations that include projects related to care coordination and social services, ACAP and CHCS said the agency does not typically approve direct funding for social determinants interventions.

“CMS may consider approving demonstrations that increase investment in, and access to, targeted social determinants of health interventions and work-related supportive services,” the organizations advised.  

“This focus is consistent with the general push toward value-based payments, upstream prevention, and cross-sector collaboration.”

Enable payments based on outcomes for social determinants interventions

CMS should also consider supporting state organizations that make value-based payments instead of those that pay for the actual services themselves, the report said.

The report discussed how the Social Impact Partnerships to Pay for Results Act (SIPPRA) will enable federal funding of outcomes payments for health-related projects. ACAP and CHCS suggested that CMS encourage this model in managed care organizations.

“CMS could consider building upon this precedent through approval of state demonstrations or guidance on appropriate use of these outcomes-based payments in the managed care environment,” the entities said.

Going forward, CMS and federal policymakers will help advance social determinants of health work and will allow states to examine patients’ socioeconomic circumstances and improve care delivery.

“In an effort to improve health outcomes and provide more efficient care, states have increasingly incentivized or required Medicaid managed care organizations and other health care organizations to develop specific systems and processes to address social needs,” the report concluded.

“As state Medicaid agencies and innovative health plans continue to experiment with ways to realign incentives and advance value-based care, many Medicaid stakeholders will continue to test innovative social determinants of health strategies, while watching for signals from CMS and other federal policymakers.”


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