Rachael Matulis, MPH

May 2, 2018


There is increasing recognition that medical care is only one of several factors affecting health outcomes. In February, a national CHCS webinar, made possible by The Commonwealth Fund, explored early state approaches for using Medicaid accountable care organizations (ACOs) to address social determinants of health (SDOH) as a way to improve health outcomes and contribute to potential savings. The webinar zeroed in on two state Medicaid ACO programs that prioritize SDOH: Minnesota’s Integrated Health Partnerships (IHPs) and Rhode Island’s Accountable Entities (AEs).

CHCS recently spoke with Mat Spaan, Manager, Care Delivery and Payment Reform, Minnesota Department of Human Services; Deborah Faulkner, President, Faulkner Consulting Group; and Deborah Morales, Senior Consulting Manager, Conduent at Rhode Island Executive Office of Health & Human Services to follow-up on key questions raised during the webinar.

“Minnesota adjusts IHPs’ quarterly population-based payments for social risk factors, including homelessness, mental illness, substance use disorder, past incarceration, and child protection involvement.”

Q: What are some examples of health equity or SDOH-related metrics, and how are they being used in Minnesota’s IHP and Rhode Island’s AE programs?

A: Rhode Island plans to measure AEs based on the percent of their attributed population screened for SDOH. The AE’s pool of shared savings (or losses) is adjusted based on performance on this (and other) quality measures. Minnesota requires IHPs to propose at least one health equity measure tied to interventions intended to reduce health disparities among the IHP’s population. For example, one IHP is addressing food instability and insecurity through a partnership with Second Harvest. The IHP has equity measures focused on the number of people referred for and receiving services, such as Supplemental Nutrition Assistance Program (SNAP) and/or food boxes from Second Harvest. Minnesota’s population-based payments — which are quarterly care coordination payments for each member attributed to the IHP — are impacted, in part, by performance on health equity metrics.

Q: How are ACOs in Minnesota and Rhode Island addressing maternal and child health? For example, are there specific initiatives to support children’s healthy development in order to “break the cycle” of disparities?

A: One key method used by both states is to incorporate quality measures related to maternal and child health into the ACO programs. For example, Minnesota assesses IHPs’ performance based on a number of pediatric-related quality measures, including childhood and adolescent immunizations; weight assessments and counseling for children and adolescents; annual dental visits for children; and adolescent mental health and depression screening. Rhode Island plans to assess AEs on similar quality measures, such as weight assessment and counseling for children and adolescents and developmental screenings in the first three years of life. Further, Rhode Island’s AEs must define a member contact and engagement approach designed to recognize that: (1) the roots of many problems are based in childhood traumas; (2) many of the highest-need individuals have a basic mistrust of the health care system; and (3) many members may not be affiliated with a primary care provider.

Q: How does social risk adjustment work in Minnesota’s IHP program?

A: Minnesota adjusts IHPs’ quarterly population-based payments for social risk factors, including homelessness, mental illness, substance use disorder, past incarceration, and child protection involvement. In other words, the base rate for the population-based payments will vary by the risk and social complexity of each IHP’s attributed population, with additional payments to account for the complexity and difficulty of managing care for those experiencing the identified social risk factors. 

“The Minnesota Department of Human Services administers a number of health and social services programs, which enables the Medicaid agency in Minnesota to access relevant SDOH data through state administrative data.”

Q: How does Minnesota’s Medicaid program have access to detailed SDOH data?

A: The Minnesota Department of Human Services (DHS) administers a number of health and social services programs, including Medicaid, Child Protective Services, Housing and Homelessness Programs, and SNAP. This enables the Medicaid agency in Minnesota to access relevant SDOH data through state administrative data. For example, the poverty metric and housing instability metrics use addresses from DHS’ eligibility and enrollment system. DHS analyzes this data for information, such as whether Medicaid beneficiary addresses are for homeless shelters or whether addresses are changing frequently. Data on substance use disorders and mental health disorders come from Medicaid claims data. DHS also worked with the Department of Corrections to access data on prior incarcerations, and is currently working with Second Harvest to obtain data on food insecurity.

Q: How are Rhode Island and Minnesota incorporating community health workers into their ACO programs?

A: Community health workers — also referred to as promotores de salud, health navigators, or liaisons — can play a key role in facilitating connections with community resources and addressing SDOH for patients with complex needs. Rhode Island specifically asked potential AEs in the AE application to comment on the extent to which the organization’s care management capacity includes a well-defined set of providers, including community health workers. Minnesota does not have specific requirements related to community health workers, but one of the core principles of the IHP program is to ensure emphasis on primary care, with flexibility to include a role for non-traditional primary care providers. Further, the state allows eligible providers to bill for services provided by community health workers.

“Rhode Island specifically asked potential AEs to comment on the extent to which the organization’s care management capacity includes a well-defined set of providers, including community health workers.”

Q: What are examples of some of the SDOH screening tools being used in Rhode Island and Minnesota?

A: Rhode Island requires that AEs screen their attributed populations for SDOH, but does not mandate use of a specific tool. Examples of the SDOH screening tools that AEs plan to use include the Health Leads Screening Toolkit; the Accountable Health Communities Health-Related Social Needs Screening Tool; and the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). Minnesota does not require IHPs to screen for SDOH nor does it require use of a specific SDOH screening tool.

Q: How can community-based organizations be funded to help ACOs meet quality and cost goals? For example, do the ACOs pay them a fee and/or share savings?

A: In Minnesota, IHPs are exploring various approaches to fund community-based organizations, including in-kind support, sharing a portion of any earned savings, and direct payments tied to shared clients. In Rhode Island, AEs are eligible to receive incentive funds, which help to provide startup funds to support investments in AE capacity. Rhode Island requires that 10 percent of AE performance incentive funds be allocated to establishing partnerships between AEs and community-based organizations. The distribution of AE incentive funds is contingent upon AEs meeting performance metrics outlined in the Health System Transformation Project Plans and serves as a time-limited opportunity to earn start-up funds in years one through four of the AE program. The expectation is that AE shared savings would ultimately replace the incentive funds.

“In Rhode Island, a critical lesson has been the importance of establishing a ‘top-down’ focus on SDOH to ensure that social needs are built into the framework of what AEs are trying to accomplish day-to-day.”

Q: What key lessons would you share with states interested in addressing SDOH via their Medicaid ACOs?

A: Although the science behind social risk and effective SDOH-related interventions is still developing, Minnesota capitalized on existing research projects and activities; good working relationships with health care systems and community-based organizations; and flexibility in the IHP program that allowed for experimentation. Minnesota took a “good is better than perfect” approach that includes ongoing cycles of review, reassessment, and periodic changes as needed. In Rhode Island, a critical lesson has been the importance of establishing a “top-down” focus on SDOH to ensure that social needs are built into the framework of what AEs are trying to accomplish day-to-day. This includes, for example, having representatives from community-based organizations serving on AEs’ leadership and governance structures. Similar to Minnesota, Rhode Island is also allowing for a period of testing and learning as AEs determine how best to integrate new tools, referral management processes, and outcomes related to SDOH within their everyday work.

For more detailed responses to these questions, as well as additional responses highlighting relevant work related to key questions from the webinar, download the complete Q&A.

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