MA Plans Slowly Begin Integrating SDOH into 2020 Plan Benefits

September 24, 2019 - CMS efforts to empower Medicare Advantage plans to tackle social determinants of health (SDOH) led mainly to the expansion of existing benefits but not the addition of new benefits, stakeholders told the Robert Wood Johnson Foundation (RWJF) in a recent study.

“Plans were supportive of new benefits but were reluctant to expand offerings rapidly,” the study, which outlined viewpoints from payers, industry experts, and other relevant stakeholders stated. “They say most Medicare Advantage plans expanded benefits in piecemeal fashion, most often addressing meal delivery and adult day care.”

The Medicare Advantage population, particularly dual eligibles, need assistance in social determinants of health but until now Medicare Advantage plans have not had enough flexibility to provide it.

Additionally, industry experts have pointed to deficiencies in chronic disease outreach, the report noted. Despite estimates that 70 percent of Medicare beneficiaries in 2018 had at least one chronic disease, a study showed that Medicare Advantage and Medigap beneficiaries did not receive  enough follow up regarding their chronic disease management.

To curb the inefficiencies in both areas, CMS extended Medicare Advantage’s benefits for 2020 specifically to increase beneficiaries’ options in chronic disease management and handling social determinants of health.

In a series of interviews conducted both before and after CMS made these changes, RWJF researchers found that creating MA benefits to address the SDOH is easier said than done. The interviews with five key payers, industry experts, and other stakeholders revealed that most believe the CMS changes to be a positive step forward, but the guidelines still need some work.

CMS will only allot about $107 per Medicare Advantage beneficiary per month to develop and sustain these benefits, according to some interviewees.

“I think it’s awesome that the opportunity is here now, but in order to get plans to buy in and this to be scalable and sustainable, I think there are just some other changes that are going to have to happen,” said an unnamed interviewee.

The interviewees offered three ways that CMS and Medicare Advantage plans could change their approach to produce the desired results.

First, if CMS allowed payers to target their benefits based on social needs data in addition to clinical criteria, interviewees stated that the effect might align more with CMS’s intentions.

Currently, CMS only allows payers to target their benefits based on clinical criteria. Interviewees commented that data such as emergency department visits, ICD -10Z social adversity codes, and other social determinant indicators can better assist payers in identifying beneficiaries who need intervention through a new benefit.

Second, the industry experts focused some of their comments on Medicare Advantage plan improvements, namely broadening Medicare Advantage plans’ experience with social determinants of health.

For some interviewees, that meant working with a Medicaid product, though others disagreed, arguing that the target audience for Medicare Advantage is critically different from Medicaid. One interviewee recognized Medicare Advantage plans’ technological and contracting deficiencies, which require improvement.

Some interviewees suggested intermediaries between Medicare Advantage payers and organizations, but others commented that this approach might force providers’ payments even lower as payers must pay for middlemen.

Third, interviewees pointed out that increasing certain supplemental benefits in Medicare Advantage could create health disparities between Medicare Advantage and traditional Medicare beneficiaries. Geographic factors, such as rebates and provider networks, could also drive disparities.

One interviewee also noted that the disparities could extend even into Medicaid as providers find they can get higher reimbursements through Medicare and Medicare Advantage.

Despite the need for improvement, four of the five payers interviewed planned to expand their programs.

Food insecurity was the top social determinant of health that payers chose to address. Three of the five payers along with industry experts noted that meal delivery was often included in plans’ expansions. Some payers targeted their efforts, using clinical data, to identify patients who had diabetes, cardiovascular problems, or chronic obstructive pulmonary disease.

Daytime assistance for seniors was the second most prevalent benefit expanded under the new CMS requirements, with two insurers offering a day care option.

Two payers also said they offer home safety improvements, personal home helpers, and navigator support by phone.

Only one payer covered transportation and one insured acupuncture and massage therapy.

Although payers’ uptake of the new benefits was slow and they shared reservations about the future, experts anticipate higher usage in 2020. All five interviewed payers were considering or committed to scaling up 2019 benefits and adding new benefits for 2020.