Medicaid Programs Seek to Address Social Determinants of Health

April 18, 2019 - From fee-for-service to managed care, Medicaid programs are seeking to address the social determinants of health (SDOH) for a broader population of enrollees in order to achieve better health outcomes, according to an issue brief from Manatt Health and the Robert Wood Johnson Foundation.  

Although state programs have previously addressed demographic-based factors for targeted enrollee populations, the shift to value-based care has led to more widespread and tailored social determinants initiatives.

“States are expanding the scope and intensity of efforts to address social factors, reflecting their interest in paying for cost-effective improvements in health outcomes, rather than the volume of medical services provided,” the brief’s authors stated.

“While states historically have had some experience tackling such issues for specialized, high-need populations (e.g., disabled enrollees with mental illness or HIV/AIDs), they are now confronting whether, and how, Medicaid should address SDOH for a broader population of Medicaid enrollees in order to achieve better health outcomes.”

Researchers set out to examine the new practices states are implementing to address social factors using Medicaid 1115 waivers and managed care contracts.

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The team found that many states are aiming to move beyond screenings, and instead connect enrollees to social supports. While 35 out of 39 states now require or encourage managed care organizations (MCOs) to screen enrollees for social issues and provide referrals to services, the brief noted that these simple screenings can be ineffective for many people.

“An individual with significant social needs, combined with complex health needs, may not have the ability or resources to follow up on a referral. Even if they do, it is possible that the agency or organization to which they have been referred to cannot help as anticipated,” the report stated.

“Recognizing that screenings and referrals can become a ‘check-the-box’ exercise, a number of states are establishing more robust MCO requirements to connect people to social supports.”

Some states are now requiring the use of closed-loop referrals, which ensures that plans track the outcomes of referrals that are made, and provide additional help as needed. Other states, such as New Hampshire and Virginia, are requiring the use of a standardized screening tool or standardized screening elements, and specifically defining the social domains that need to be addressed.

Additionally, several states are requiring that MCOs work with community health workers, or contract with locally-based staff for care coordination purposes.

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“This reflects a belief that local staff are likely to have more on-the-ground knowledge of community resources and the members’ lived-experience, but also the ability to meet in-person with someone to address social needs,” the brief said.

“For example, New Mexico requires MCOs to make community health workers available to members for assistance in navigating the health care system; securing culturally appropriate health information; and obtaining information on community resources.”

States are also seeking to expand the scope of social determinants of health interventions to include more patient populations and social issues. Rather than focus on enrollees with complex health conditions, programs are now considering the social and economic factors of all members. Some states are also looking to address social isolation and loneliness, as well as alleviate the effects of adverse childhood experiences.

In addition to moving beyond standard screenings and interventions, states are working to build stronger networks of community-based organizations and collaborations with providers.

“Increasingly, state Medicaid agencies are recognizing that addressing social factors via Medicaid requires stronger coordination with, and support for, community-based social service organizations,” the brief said.

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“In particular, many community-based organizations have little or no experience working directly with health care providers and plans, and have historically been funded through grants, rather than billing for services.”

Medicaid agencies are using Medicaid 1115 waivers to strengthen community-based organizations, with states such as New York, North Carolina, and Rhode Island securing 1115 waivers that explicitly require some sort of investment in community-based organizations that provide social services.

To implement the practices discussed in the brief, researchers said that states should begin by reviewing existing evidence on the effectiveness of social determinants interventions across Medicaid populations.

States should also convene providers, state social service agencies, and other stakeholders to build partnerships with social service organizations, as well as revise Medicaid managed care contracts to integrate social determinants strategies.

Modifying or seeking a 1115 waiver can also help states expand their social determinants efforts, the brief said.

“Some of the practices outlined above, such as using Medicaid dollars for some health-related services that do not fit into a Medicaid benefit category, may require a Medicaid 1115 waiver,” the report stated.

“To the extent a state is including a focus on SDOH into an existing or newly-proposed Medicaid 1115 waiver, the key often is to secure CMS approval to use Medicaid matching funds for activities that are not otherwise matchable.”

Going forward, it will be necessary for both payers and providers to address patients’ non-clinical factors in order to improve health outcomes.

“Increasingly, SDOH interventions will be more closely integrated into the delivery of care,” the report concluded.

“As these interventions expand, it will be important to measure their impact, and recognize (and determine how to address in payment strategies) that some of the benefits of addressing social factors may have a long-term impact and may also benefit programs and entities outside of Medicaid.”