top of page

Changing What "Counts"

America’s steady transition to value-based care is reframing a critical influencer of health – social determinants – from a mission-driven investment to a business imperative. This evolution is fueled by recent decisions to “count” social health care as a covered benefit in public and private insurance programs.

Why does this matter?

  • It shifts expectations. Incorporating social health as a reimbursable service goes some way to normalizing the practice and expense of this care for providers and payers. For patients, discussing social health with a caregiver begins to shift what they expect from health care.

  • It drives performance. When managing total cost of care, social health factors impact revenues. But how much? For years, the strongest answer to that question relied on proxy measures, and data from discrete pilots. That is about to change. As more Americans receive this benefit from their insurer or health care provider, executives will have stronger and cleaner data to understand what the specific ROI is for these services. It’s important to note that capitation or sub-cap arrangements are not required to measure ROI for social health services. Markets with even modest transitions to value-based contracts are likely to find a positive ROI on this investment, especially if targeted to high-risk populations.

  • It improves health. In the past, health systems and payers that have invested in social health services limit eligibility for these benefits based on assessment of risk. In practice, this usually means that adults with chronic conditions or complex care needs are targeted for social health programs. Not only are these individuals the most time-intensive for providers and payers, they also typically represent the largest opportunity for gain – both in improving health outcomes, and in reducing total cost of care. While this strategy absolutely has merit (and short-term gain), it is not designed to prevent or reduce risk factors in children or adults who have yet to develop these difficult and costly conditions.

Recent Case Studies

Public Payers

In April of this year, the Centers for Medicare and Medicaid Services (CMS) announced a significant expansion in how Medicare Advantage plans may design “primarily health-related” services. Medicare Advantage plans have long had the flexibility to offer supplemental services to their members, such as coverage for hearing aids or eyeglasses, gym memberships, or dental benefits. Beginning in 2019, MA plans may incorporate additional services in their benefit structure to “diagnose, prevent, or treat an illness or injury; compensate for physical impairments; ameliorate the functional or psychological impact of injuries or health conditions; or reduce avoidable emergency and healthcare utilization.”

What this means in practice is that MA health plans have even greater flexibility to assess and fulfill social health needs of their 20 million members, like providing air conditioners for members with asthma, or healthy grocery deliveries for members with food insecurity. Members might benefit from new transportation, home modification services, or other interventions to improve health and maintain independence. While plans are not required to incorporate these new services in their benefit plans, the research is clear that factors like adequate food, safe housing, or strong social networks can have a significant and immediate impact on health and stability of patients, whether they are relatively healthy or struggle with disease or injury. For MA plans competing on value, these modest investments could yield extraordinary improvements in patient health outcomes, and in lowering total cost of care.

Private Business

Private businesses are also investing in services to understand and address social determinants of health. Earlier this month, UnitedHealthcare announced multi-million dollar investments to improve social determinants of care across five states: Wisconsin, Arizona, Missouri, Texas and Louisiana. In Wisconsin alone, UnitedHealthcare awarded $1.95M in grants to improve access to fresh foods, and school-based dental and vision care for children.

Intermountain Healthcare recently launched the Utah Alliance for the Determinants of Health, committing $12M over three years to focus on non-medical factors that affect health, such as food insecurity, housing instability, interpersonal violence, or transportation. The Alliance brings together city, county and state government agencies, community-based organizations and local health care providers in two inaugural cities, Ogden and St. George, with the goal of scaling statewide in future years.

18 views0 comments
bottom of page