Medicaid managed care organizations (MCOs) are important partners in helping states identify and address the social risk factors that contribute to poor outcomes. As such, Medicaid agencies are increasingly using value-based payment and managed care initiatives to respond to unmet health-related social needs (HRSN) in an effort to improve health outcomes, reduce health care spending, and advance health equity.

With support from the Episcopal Health Foundation and coordinated by the Center for Health Care Strategies (CHCS), the Texas Managed Care Organization Social Determinants of Health Learning Collaborative (learning collaborative) has been working for the past two years with Texas’ Health and Human Services Commission (HHSC) and Texas’ Medicaid MCOs to support implementation of strategies that address Medicaid enrollees’ unmet HRSN. With a commitment to quality improvement, HHSC recognizes the importance of partnering with MCOs to tackle social needs and improve the health and well-being of Medicaid members.

CHCS recently spoke with HHSC’s Andy Vasquez, Deputy Associate Commissioner of Quality & Program Improvement, and Ryan Van Ramshorst, MD, MPH, Medicaid Chief Medical Director, to learn about Texas’ strategy to address Medicaid members’ unmet HRSN.

Q: Through the learning collaborative and development of the DSRIP Transition Plan Milestone, Assessment of Social Factors impacting Health Care Quality in Texas Medicaid, HHSC has begun to develop a strategy to address HRSN. What is the impetus for this and what will be some key components of Texas’ strategy?

As a Medicaid program, we deliver medically necessary services, but this is all for naught if we don’t address the non-medical factors that might be impeding a person’s ability to access that care.

R. Van Ramshorst: It’s well documented that a small percentage of a person’s health status is attributable to medical care, but a much larger percentage is attributable to social determinant factors. As a Medicaid program, we deliver medically necessary services, but this is all for naught if we don’t address the other non-medical factors that might be impeding a person’s ability to access that care. We believe our managed care service delivery model promotes innovation and gives us the necessary flexibility to address social determinants of health (SDOH) and make strides in improving quality outcomes.

Q: How has the learning collaborative helped shape HHSC’s work around addressing social needs among Medicaid members?

R. Van Ramshorst: As we enter year three of the Learning Collaborative, it’s a reminder that addressing SDOH is a priority for Texas’ MCOs. Sometimes managed care doesn’t get a great name, but we have a diverse group of MCOs in the collaborative ― some large, small, for-profit, and not-for-profit ― all coming together and saying that this issue matters, how can we work together.

A. Vasquez: The learning collaborative structure has created an environment that we don’t have in normal dealings with our MCOs. It’s easy to fall into old patterns ― conversations where HHSC is setting direction and the MCOs are trying to be compliant. The collaborative creates equal footing for the plans and HHSC, which enables us to dive into topics without that traditional state/MCO relationship impeding open discussions.

Q: In setting a priority to address SDOH, how did the state’s DSRIP program provide a platform for this work?

A. Vasquez: Addressing SDOH has really been at the core of delivery system reform incentive payment (DSRIP) in Texas. Providers were required to complete regional needs assessments, which offered a local view of clinical and social needs. DSRIP providers then developed projects and services responsive to these community-identified needs and priorities. From early on, they have centered on addressing social factors that impede good health outcomes, in both the Medicaid population and the uninsured. As a result, DSRIP has very much been a catalyst and learning opportunity for HHSC to move forward with addressing HRSN.

Q: In what ways do alternative payment models (APMs) factor into the state’s SDOH strategy?

A. Vasquez: For several years, we have required our MCOs to implement a certain threshold of APMs and to improve quality ― which has created flexibility and willingness on the part of MCOs to test new models. While we do not have contract requirements for MCOs to address a particular social risk factor, there is the appetite to look beyond traditional clinical approaches to address SDOH. The recent guidance on quality improvement creates possibilities for MCOs that they are acting on already, and we want to continue to encourage that. 

APMs offer a framework and real promise to address SDOH… [allowing] us to work with MCOs to financially support non-clinical providers to address SDOH.

R. Van Ramshorst: We recognize that the fee-for-service model is not a good mechanism to support nontraditional providers, like community health workers, doulas, or community-based organizations (CBOs). APMs offer a framework and real promise to address SDOH in the Texas context. We believe APMs will promote innovation and allow us to work with MCOs to financially support non-clinical providers to address SDOH.

Q: How will MCOs and other stakeholders be encouraged to engage with Medicaid enrollees to inform and implement an SDOH strategy?

R. Van Ramshorst: We recognize that connecting with the end user more directly is incredibly important. Given that community needs are so individual and can vary tremendously across regions, having that consumer input can really be an asset to identifying and addressing community priorities. It’s not easy, and historically we have relied on consumer advocacy organizations, but we can do better.

A. Vasquez: This is a new area and one that we intend to grow. MCOs have responsibilities to connect with members, which is analogous to the DSRIP local needs assessment. MCOs operate within defined service areas and are able to understand the unique needs of their members. Getting this information from our MCOs is our main touchpoint with Medicaid members, but we will continue to look for opportunities to engage directly with beneficiaries. Our Value-Based Payment and Quality Improvement Committee, as well as the SDOH subcommittee, are very interested in how we are addressing SDOH and health disparities while advancing equity. We feel there is a real opportunity here to work with Medicaid members on these issues. 

Another voice missing from our discussions are CBOs that are delivering these social services. These organizations exist outside the Medicaid program, but we feel there is more we can do in partnership with the MCOs to build CBO capacity and scale their services.

Q: Through the learning collaborative, you’ve reflected on the value of thoughtful preparation, coordination, and partnership. How do you see Texas’ plan for addressing SDOH as achieving this goal?

Medicaid cannot go at this alone…We need to better understand how to lean on other sectors, like education and workforce development, to get at these social factors because, at the end of the day, it requires investment of funds, which can be challenging for Medicaid.

A. Vasquez: We appreciate that there are a lot of unknowns and a lot of ways to approach this work, which can lead to a sense of being overwhelmed ― and in a bureaucracy, might lend itself to inaction. HHSC needs to be thoughtful in our approach to mitigating both these risks. Addressing SDOH is also a new environment for our policymakers. This includes policies that are expressed in contracts, quality metric targets, and financial incentives. As we develop our SDOH action plan, we need to be bold in what we put forth, but not overly aggressive. Practically speaking, we need to articulate our vision and the specific actions required to achieve this vision to stakeholders so that our colleagues in other state agencies, state policymakers, MCO staff, and consumers all understand what we are trying to accomplish. It is amazing to have HHSC staff and our MCOs ― who are both mission-focused ― as well as our leadership working together to move this work forward. This all speaks well for the possibility of success.

R. Van Ramshorst: Another reason we must be thoughtful about the SDOH action plan is that Medicaid cannot go at this alone. Medicaid has a huge role to play. But we need to better understand how to lean on other sectors, like education and workforce development, to get at these social factors because, at the end of the day, it requires investment of funds, which can be challenging for Medicaid. This is not unique to Texas, but we need to figure out how to partner with other resources out there.

A. Vasquez: Also, it’s especially true in Texas that addressing SDOH is not typically thought of as Medicaid’s responsibility. So, there is a lot to overcome to change longstanding foundational perspectives on what role Medicaid should play.

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