Leveraging Social Determinants for Medicare, Medicaid Engagement

December 18, 2023 - Medicare and Medicaid populations encounter significant obstacles to care because of social determinants of health, such as economic instability, lack of transportation, isolation, and food insecurity.

Social determinants of health, according to the Office of Disease Prevention and Health Promotion, are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” These conditions have the largest impact on health outcomes, with social determinants impacting as much as 50 percent of county-level variation in health outcomes. In contrast, clinical care accounts for just 20 percent, per the Office of Health Policy.

Populations most impacted by social determinants of health include older adults, children, people with disabilities, and people with chronic conditions. Many of these individuals are covered by government-sponsored programs, such as Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

Engaging members in Medicare and Medicaid plans is a major challenge for payers, largely because of these social determinants of health. However, health plans can leverage data to identify the social determinants affecting their members and incorporate those insights into member engagement and benefit design.

“One of the more important things to consider for a member engagement strategy is the propensity of a member to engage,” says Kristen Gasteazoro, senior vice president of SmartShopper Sales and Client Performance at Zelis.

Member engagement is highly personal. Some members prefer email, while others are more likely to respond to a phone call. How a plan communicates with a member affects if and how they engage. Plans also need to consider the type of programs these populations will respond to. Do they need a nudge to get their flu shot or a more concerted effort to improve chronic condition outcomes? Do members respond to incentive programs?

What social determinants are prevalent within a population can significantly impact the effectiveness of member engagement and messaging.

“If there is an individual who is interactive in their daily life — going out with friends, going to the post office, has a driver’s license, maintains day-to-day activities — they’re probably more likely to interact with the healthcare system in general,” Gasteazoro says.

In contrast, members who face social determinants like social isolation or lack of reliable transportation may not be as active in their healthcare decision-making and, therefore, may be part of a harder-to-reach population, according to Gasteazoeo.

“You can look at that behavior to find how it correlates with member engagement,” she states.

Program design must take into account how a person interacts with the environment around them to be successful. Health plans understand this and many are investing significantly in ancillary services, such as ridesharing and virtual care to bridge the gaps left by transportation insecurity, economic instability, and other social determinants. Another major benefit plans are offering is food-as-medicine programs that aim to mitigate the impact of food insecurity and economic instability.

Research shows that these benefits can improve outcomes for members, especially those with chronic conditions and excessive healthcare spending. Consequently, these benefits also align with other health plan priorities, such as Healthcare Effectiveness Data and Information Set (HEDIS) and other quality scores, risk adjustment optimization, and member satisfaction.

However, health plans should also incorporate what they know about social determinants of health into their member engagement strategies in order to be successful in Medicare and Medicaid markets.

“Messaging should be different based on social determinants data,” Gasteazoro states. “The messaging a plan uses should be different for each member, as well as the vehicle it uses to communicate that messaging, like using app notifications versus an email message.”

For example, members may not be compliant because messaging and/or the way plans communicate do not resonate with them. Text reminders may not work for older adults who are not confident smartphone users. Additionally, some members with lower education or health literacy levels may not respond to messaging because of knowledge gaps, which plans need to address with more teaching opportunities and educational content.

Similarly, plans may consider a member population’s income level when designing programs to encourage healthy behaviors. Incentives are likely to resonate with lower-income populations to encourage them to get a vaccination or attend a wellness visit.

“All of that can play into member engagement. For that reason, it becomes challenging for plans to implement the right programs,” Gasteazoro explains.

Adding to the challenge is data collection. Health plans sit on a gold mine of claims data, but research indicates that information on social determinants, even race and ethnicity, are not always present on claims. Many EHRs also lack space for providers to record and code items like food insecurity, lack of transportation, and other lifestyle factors. This was especially an issue for Medicare Advantage providers, according to the study.

Health plans need to leverage other sources of data, including health risk assessments, direct member surveys, and outside data sources, like the US Census.

“Collecting social determinants of health data may not be a health plan’s strongest capability, and they should be collecting more than just social determinants data to tailor member engagement,” Gasteazoro elaborates. “Plans can tap into credit data or financial data to gain a clearer picture of members and how they might engage.”

However, accessing this type of data depends on a plan’s size and access to resources, she notes.

Health plans, like most stakeholders in the healthcare industry, need help identifying, capturing, and addressing social determinants of health to improve outcomes and reduce avoidable spending. Plans can turn to vendor partners that specialize in member engagement to shoulder the load. These partners focus entirely on understanding how consumers engage with healthcare and their plan, whether that is which doctors they choose to see, how they like to be communicated with, or what motivates them to achieve wellness.

Barriers to data collection, regulatory burdens, and budget limitations make it difficult for plans, especially in the Medicare and Medicaid space, to prioritize the many layers of member behavior and engagement.

Incorporating social determinants of health data into member engagement and benefit design is vital to improving outcomes and spending associate with Medicare and Medicaid populations. These members are disproportionately affected by non-clinical factors that impact the way they engage with the healthcare system. Plans need to have a strategy in place to identify and address social determinants of health in order to implement a communications strategy that leads to positive change.

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