Expanding Social Determinants of Health Benefits Among Public Payers

October 11, 2021 - HHS needs to expand the list of social determinants of health that public payers can cover and hold public payers accountable to covering preventive services that can help address social determinants of health, the Bipartisan Policy Center said in a report.

“The U.S. can improve population health and health outcomes by integrating social services with the health care system and addressing SDOH before they lead to or exacerbate chronic illness,” the Bipartisan Policy Center stated. 

"To do so, BPC believes it is necessary to both improve the coverage of and access to primary care and preventive services. We recommend a multifaceted approach that improves insurance coverage of preventive and nonmedical services in the Medicaid program and strengthens the primary care workforce through an independent evaluation of workforce shortages, greater use of telehealth and technology, and higher reimbursement rates for select services in Medicaid.”

In order to enhance coverage for social determinants of health, the Bipartisan Policy Center recommended that the Secretary of the Department of Health and Human Services (HHS) have the power to further expand the list of nonmedical services that Medicaid programs can cover.

The expansion could entail redefining nonmedical services that qualify for coverage. For example, the term could refer to any service that has proof of enhancing or sustaining health outcomes. 

In order to expand the definition of qualifying nonmedical services, HHS and CMS could reference any interventions that the Community Preventive Services Task Force has approved and found cost-effective. For 2020 to 2025, the Community Preventive Services Task Force is focusing on topics such as mental health, stroke prevention, and injury prevention.

To that end, the Bipartisan Policy Center urged HHS to offer more financial support for studies that provide such proof, analyzing the costs and benefits of various nonmedical interventions.

Reimbursing for social determinants of health is not the only challenge that public payers face. They must also address social determinants of health when the payers find them. 

To that end, the Bipartisan Policy Center recommended that public payers should be held accountable for covering preventive care services. Even in non-expansion populations, payers should be covering preventive services without any cost-sharing, the think tank argued.

Most Medicaid programs have not taken advantage of the one percent bump to federal medical assistance percentage (FMAP) that states can receive when they cover the Affordable Care Act’s list of required clinical preventive services—this FMAP boost was unrelated to the increase that CMS used to support states’ efforts against the coronavirus pandemic in 2020.

The Bipartisan Policy Center suggested that CMS should release guidance around community health worker (CHW) reimbursement, beyond the specifications around CHWs that CMS outlined in its managed care plan contracting strategies. 

CHWs include health advisors, peer counselors, and patient navigators. Studies have highlighted that CHWs are often at the front lines in healthcare and, as a result, are in a position to see and address social determinants of health.

“Coverage of CHWs has proven to be effective in addressing health care disparities in minority and underserved communities, improving outcomes, and reducing Medicaid costs for some populations and conditions,” the report explained.

“However, states and their representatives have indicated that CMS has not put forth adequate clarifying information on each of the pathways states can take to cover CHWs.”

HHS should assess the role of CHWs in primary care and preventive care services as well as leverage the overlaps between the Community Preventive Services Task Force’s recommendations and the services that CHWs typically provide.

In addition to this, the center pointed out the dramatic provider shortage. The report noted that this is not just a provider problem, but that public payers have a role to play in improving access to care and strengthening the Medicaid provider workforce by boosting Medicaid reimbursement rates.

Primary care, prenatal, and postpartum services—which have proven to be more effective with continuous coverage—should receive higher FMAP rates for the next five years so that public payers can reimbursement matches commercial rates.

The report also recommended integrating clinical and community-based services. Electronic health records, telehealth, and remote patient monitoring tools will be essential to that effort.

Medicaid programs are well-positioned to make headway on social determinants of health barriers, but the Bipartisan Policy Center made it clear that states may require federal support to fully exercise that capability.