- Engaging in meaningful risk stratification of beneficiaries requires accurate data that can highlight opportunities to reduce costs and improve outcomes for plan members.
In order for payers to develop accurate and detailed risk stratification frameworks, they need to incorporate all available data on their beneficiaries, including data on the social determinants of health (SDOHs) that may impact outcomes outside of the clinical care system.
Gabriel Medley, Vice President of Quality Improvement and Risk Adjustment at Gateway Health, believes that incorporating social determinants of health data into the risk stratification process allows health plans to better predict potential healthcare outcomes across disparate populations.
“The social determinants of health will help us understand the different needs of our beneficiary markets, such as if members live in an urban or rural environment,” Medley explained.
“Members could be difficult to engage if they live in a place where there's no bus system, if they have trouble with buying food, or if they experience other possible lifestyle challenges,” he said.
Gateway Health serves around 600,000 Medicare and Medicaid managed care members across seven states, including Pennsylvania, Delaware, West Virginia, Ohio, Kentucky, Arkansas, and North Carolina.
“In the managed care environment, we need to understand what's driving costs,” Medley said.
“The social determinants of health are an indirect way of looking at how costs impact healthcare.”
In order to integrate socioeconomic data into risk stratification techniques, payers need to access relevant data that can inform organizations about a population’s socioeconomic challenges to healthcare.
Social determinants of health may include long-term socioeconomic barriers to accessing adequate healthcare services. SDOHs can be complicated and difficult to observe without accurate and relevant data. Fragmented or unstructured social determinant data may also impede a payer’s ability to assess beneficiary risks.
“If payers don't have the most current information and they are not retaining it, or recycling it for use, that's where an organization can stifle,” Medley said.
“We want to manage a cohort that's at high risk of going to the ER or being admitted to a hospital,” he added. “And then we have members that have slightly lower expected costs and would be in the medium category. The lowest risk members are people that have minimal utilization rates, such as going to the doctor once a year.”
Both claims data and government data can provide valuable layers of detail about where beneficiaries work and live. Combining both claims and community-level data allows payers to evaluate opportunities to improve member care quality as well.
“The government has a lot of census data that payers could use,” Medley said. “For example, government data can determine if a beneficiary is an active voter, which could mean the member is moving around, has access to adequate transport services, and is likely to answer the phone.”
“Supplemental data such as pharmacy, lab, and behavior health data are available at the local and county level,” he continued.
“We get information back from the state that informs us about vaccines, lead screenings, and other metrics that we can aggregate together. Using both claims and government data creates this powerful combination to help us maximize our intervention tactics to reach members and drive quality improvement.”
Community representatives from Gateway Health also work to collect information from individuals. After identifying socioeconomic challenges such as limited transportation access and food insecurity at the community level, they could then incorporate this information into risk stratification processes.
Medley and his team at Gateway Health implemented a technology solution called HMS Eliza that specializes in cost and quality management, revenue management, and customer engagement to assist in SDOH data collection.
Medley and his team experimented with a variety of communication tools such as phone calls, email, social media, and text messages to reach out to beneficiaries in need of additional management. Gateway Health used HMS Eliza to record engagement rates and then survey members about socioeconomic healthcare challenges.
“Some members pick up the phone and some don't,” Medley explained. “At the end of the day, we want the member to respond. Members are more likely to engage in their health when we are contacting them according to their preferences.”
“Over time we started to record if members prefer text messaging and opt into text message engagement. Now we have data to determine how to apply the appropriate intervention tactic to engage each member, and to have the best response rate.
Customized communications may even help payers reduce beneficiary risks. Payers can use the data to create alerts that help members manage healthcare concerns and seek out healthcare services as needed.
Gateway Health’s engagement strategy and social determinant of health risk stratification model have led to improvements in chronic disease control measures.
“We’ve noticed a dramatic improvement in control measures for diabetics including blood pressure and medication adherence,” Medley said. “We have 40 percent or higher engagement rates in certain chronic disease measures.”
Medley and his team were able to increase chronic disease management performance to a point that outperformed the majority of Medicaid plans in the country.
“Gateway Health has experienced year over year improvement and our chronic disease performance metrics which increased by three to four percent,” Medley explained. “Now we have measures that are hitting the 75th percentile in Medicaid performance and we know that's attributed to increased engagement rates.”
Gateway Health’s risk stratification techniques helped the organization minimize expenses and improve spending efficiency for beneficiary services. In some instances, Gateway Health’s medical loss ratio reached 85 percent, indicating efficient clinical spending.
Medley believes payers may drastically improve member satisfaction while lowering costs if they collect, analyze, and incorporate SDOH data into their operations.
“Because members are controlling their health, or controlling their chronic conditions better because of reminders and systems that connect members to their providers, we're seeing savings on our ED visits and reduced ED visits for these cohorts,” Medley said.