People struggling to secure food and housing also struggle to stay healthy. This reality is glaringly obvious, and painfully urgent for so many. But what can Medicaid do?
Over my four years with the Center for Health Care Strategies (CHCS), I’ve helped state Medicaid agencies, health plans, and community-based organizations think through issues regarding health-related social needs (HRSN) and social care integration. Much of my work has involved partnering with states on primary care innovation efforts, specifically, and how to better identify and address unmet HRSN in the context of those efforts. This blog post outlines four lessons from the last few years for supporting health care stakeholders to meaningfully address unmet HRSN, with a focus on state activities relating to advanced primary care and Medicaid managed care.
1. Be precise with words and goals.
As the term “social determinants of health” (SDOH) crossed from public health parlance to health care topic du jour, it began to take on new connotations. This transition inspired several reflections on the power of precise terminology to drive change, and define both individual-level and community-level opportunities for impact. Several in the health care policy field suggested discrete definitions for “social needs,” “social risk factors,” and SDOH ― not to mention “population health,” “drivers of health,” and “structural determinants.”
While these terms remain in flux, the lesson remains clear: Conflation of terms and concepts can lead to confusion and misdirection. This lesson is particularly relevant as state Medicaid agencies engage in discussions around structural racism, inequities, disparities, and health equity. While it is common to discuss these concepts in the same breath as SDOH, they are distinct. Structural factors, like structural racism, negatively impact SDOH for communities that have been marginalized, and ultimately produce inequities. (Check out American Medical Association’s new Organizational Strategic Plan and the Health Equity Language Guide for State Officials for a good discussion of key terms.)
Being precise is useful not just to build consensus and shared understanding, but also to define relevant goals and activities. For example, what approaches are truly upstream and what are midstream or downstream? What activities support social care integration (i.e., awareness, adjustment, assistance, alignment, and advocacy), and who will take them on and how (e.g., across states, plans, health care institutions, and primary care teams)? How can Medicaid programs allocate and reallocate funding for strategies that improve community-level SDOH and address health inequities?
2. Strive to be more democratic, less technocratic.
Over the last four years, states have thought through how to: (a) collect, classify, and use data on social risk factors; (b) calculate a return on investment for related interventions; (c) use community information exchanges and community resource referral platforms to close gaps between health and social care; and (d) adjust payment for social risks. These approaches undoubtedly have a role in payment and delivery system reform. They offer the potential to catalyze better, more equitable, and whole-person approaches to care. But states should be careful not to lose sight of the people behind the data sets. (Hats off to Diane Sullivan, an anti-hunger and poverty advocate and consultant with lived expertise, for that reminder.)
States can move beyond the intricacies of health care organization implementation (e.g., primary care team roles, data standardization, and electronic health record integration), to the experience of care ― specifically, how these questions will be received and perceived, as well as how and in what circumstances social needs screening and referral make an impact. This new orientation puts the focus where it should be: On the people and communities that state Medicaid programs serve.
To promote health equity, states should strive to elevate the diverse voices, stories, and experiences of the people served by their programs, and co-design HRSN interventions with communities that have been marginalized. This shift is not just a grounding exercise. Robust, authentic community engagement and partnership can lead to more effective, responsive policies, and identify pitfalls that may cause unintended harm. For example, Rhode Island developed a Health System Transformation Project SDOH investment strategy, which includes participatory budgeting practices and partnerships with Health Equity Zones. Similarly, in a draft concept paper related to its 1115 demonstration, Oregon proposes ways to engage local communities in spending priorities, in partnership with its Regional Health Equity Coalitions ― building upon existing member engagement strategies employed by its coordinated care organizations.
3. Lead when you can.
Medicaid managed care is a tricky balance between innovation and standardization. There are some things that managed care organizations (MCOs) do well independently, and other things that could benefit from state leadership and direction. This need for direction and cohesion is particularly true as it relates to Medicaid’s forays into social needs and advanced primary care for three reasons.
- Medicaid has limited funds to devote to HRSN-related activities. Limited funds can be more impactful when directed toward critical HRSN, like housing or food security, in similar ways (e.g., encouraging the uptake of housing-related services and supports, or the uptake of a particular screening tool, like Hunger Vital Sign).
- Primary care teams that contract with Medicaid MCOs likely contract with several plans. It is unlikely that one MCO initiative or performance improvement project will inspire practice-level changes relating to HRSN and provide the data infrastructure to support advanced care coordination. For example, standardized data reports and feeds between MCOs and primary care teams can avoid unnecessarily duplicative (and potentially traumatizing) social needs screening at the primary care, managed care, and state levels.
- To make a community-level — not just individual-level — impact, collaboration is necessary. To the extent that each MCO, community health center, and health system has limited funding to devote to community-level interventions, that limited funding will be more impactful in the aggregate and when working in complementary, and not duplicative, ways.
In other words, borrowing from CHCS’ Texas Managed Care Organization SDOH Learning Collaborative, states can help ensure that health care organizations are rowing in the same direction, and not ending up on different islands. States can name specific priorities like food and housing security, and specific tools, like social needs screening questions and community resource referral systems. This leadership and focus can save health care organizations time and resources, and reduce unnecessary fragmentation. For example, North Carolina has taken this more prescriptive approach, with its NCCARE 360 system, Advanced Medical Home program, social needs screening questions, and a fee schedule supporting its Healthy Opportunities Pilots. States can also encourage plans to work together on community reinvestment efforts. For example, Ohio will require MCOs to reinvest three to five percent of their profits into local communities and work collaboratively with other MCOs in the region to maximize the collective impact of community reinvestment funding.
4. Pay for what you want to see.
Medicaid can pursue more sustainable, dedicated funding structures for advanced primary care and social care integration. This move is usually through value-based payment, managed care, and new benefits ― in other words, finding ways to pay for HRSN activities that align with intended goals and outcomes.
Value-based payment can be an important tool to enable more flexibility, but can catalyze change only to the extent that payment models or embedded quality measures are: (a) thoughtfully designed; and (b) a dominant source of revenue. As a recent NASEM report recommends, the goal should be to “pay for primary care teams to care for people, not doctors to deliver services.” Washington State has explored this type of flexibility in its multi-payer primary care transformation model, designed to support whole-person care.
MCOs also have the flexibility to fund social care innovations, and states can more formally advance this work. For example, California has defined enhanced care management and in lieu of services as a way to sustain innovations in its Whole Person Care Pilots and Health Homes Program, and begin to more comprehensively address California’s homelessness crisis.
Finally, state Medicaid agencies can also add formal benefits that address HRSN. (For an in-depth overview of potential Medicaid benefits that address social needs, see CMS’ recent state health official letter.) Minnesota, for example, added Medicaid benefits relating to housing stabilization services, as well as health education services provided by community health workers.
The COVID-19 pandemic has brought added funding and focus on SDOH and HRSN, with health equity as an underlying goal. Among state Medicaid agencies and their health plan, provider, and community-based partners, there is also an increasing appetite for coordination and cross-sector and cross-agency collaboration on issues relating to prevention and primary care, as well as a willingness to investigate the root causes of health inequities.
In partnership with others, state Medicaid agencies can seize this moment to make an impact.