Understanding and addressing social determinants of health (SDoH) and health-related social needs at the individual level is the critical first step in improving outcomes, reducing disparities, and reducing healthcare costs. The social determinants of health are conditions in the environment in which the people are born and live. The health-related social needs include food security, housing quality, transportation, etc. Several health plans are experimenting with programs to address social determinants of health and health-related social needs as part of their health equity strategy. Unfortunately, most of these programs are designed in an ad-hoc manner, not well integrated with other programs, and lack the disciplined approach that can provide sustainable results.

The term healthcare is local is not a cliche. The needs of every community are different. The healthcare resources, assets, and socioeconomic environments are different in every community. Even within the same community, SDoH and social needs can vary significantly between member subpopulations. For example, when you look at a specific supplemental benefit such as nutrition support, people’s preferences are different (delivery vs. pickup), driven by their culture and values.

Given the complexities of designing and implementing social needs programs and benefits, it is important that organizations take a data-driven approach to provide supplemental benefits to the right subpopulations that can benefit from them.

The data-driven iterative approach enables organizations to target the subpopulations, test and learn the right interventions that can address social needs for them, leverage technology to partner with community-based organizations to connect members to the right resources, analyze outcomes data, and course-correct when needed.

Data and analytics to identify the right services

Data and analytics to identify the right services for enhanced care management and MA supplemental benefits

In the pandemic, we have all seen the health disparities between people and communities. We have also seen that most people desire to have access to quality medical, behavioral and social needs in their communities. When designing supplemental benefits, it is important for health plans to start with a data and analytics platform to identify the right subpopulations for the interventions they are considering. Both Medicare and Medicaid have specific requirements, in general, health plans typically target high-risk, high-need members including individuals at high risk for ER use, hospitalization, and/or hospital readmission and individuals with specific chronic diseases, mental health needs, and dual-eligible. The problem is that not everyone that fits the criteria needs supplemental benefits. The data on social needs is not available in claims and is not coded in the clinical systems. To get this data, organizations should tap into additional resources such as SDoH screenings performed by the front-line staff. After you have collected the data, you’d often find that data is incomplete and duplicated across disparate systems. The member data platform can help you collect, clean, and structure your claims, and clinical and social data in one place. With the platform you get a single view of the member and get a data foundation to build member segments and profiles, as well as insights into the health-related social needs of specific member subpopulations, revealing opportunities to create interventions that improve health and deliver business value.

Customizable member benefit programs

Customizable medicare advantage (MA) supplemental benefit programs

It is prudent to start small and take a test-and-learn approach when designing enhanced care management or supplemental benefit programs. Health plans and MCOs can benefit from partnering with the communities that they are serving. Building intentional and authentic partnership with CBOs is key to success. They can share feedback on what worked and what was liked by targeted communities and can help you customize benefits before they are launched more broadly. Integrating service delivery with surveys on member satisfaction and their perceived value can provide you with the initial data you need to measure impact at the micro-level. This also provides you an opportunity to discard the interventions that are not effective, at the pilot stage.

Health plans and MCOs can benefit from a technology platform to create highly customizable member benefit programs with flexible cost-sharing to meet clinical and social needs. In addition to supplemental benefits, they can set lower cost-sharing for high-value care based on value-based insurance design (VBID) principles. In addition, plans get the flexibility to customize spending controls in the way that works best for them. This ensures an omnichannel shopping experience with multiple programs and benefits on one card that has MCC and SKU restrictions.

Connecting clinical and social care teams

Connecting clinical and social care teams for enhanced care management (ECM) and MA advantage supplemental benefits

Social needs are one component of overall care management. Most healthcare organizations and health plans prefer to keep care management in-house and want to leverage community-based organizations to address unmet social needs.

There are a lot of collaboration challenges, such as the willingness and ability of all healthcare stakeholders to work together. The use of smarter technology networks to facilitate collaboration, dispatch urgent notifications about high-risk members, and deliver critical information
to the point of service can improve coordination, cost savings, and transitions of care – critical for health plans and MCOs

to support the care continuum. Organizations can benefit from a technology-based integrated care management solution that helps them create a shared care plan incorporating interventions for both clinical and social needs. The shared care plan can include interventions for managing chronic conditions such as diabetes or COPD, transitions of care as well as services performed by CBOs including assessment and screening for social determinants of health needs, ongoing case management and coordination of care, nutrition program, home care, transitions from hospital to home, and transportation (medical and non-medical), etc. The care management solution helps care management staff to engage the targeted members and their care ecosystems to encourage and enable high-value decisions around their care and improve self-management. By implementing a closed-loop referral process, organizations can take a proactive approach to identify and addressing cases that are likely slipping through the cracks.

Measuring the impact

Measuring the impact and ROI of enhanced care management (ECM) and Medicare advantage (MA) supplemental benefits.

With the right technology foundation, organizations can start measuring the impact of their social needs programs. This can range from process measures such as # of people screened for social needs, touchpoints, and program enrollment to specific outcomes such as closure in care gaps, change in utilization of primary care, mental health and reduction in nursing home admissions, and reduced ER utilization.

Looking at the bigger picture is critical here. Health plans and MCOs should think about shifting the ROI model from short-term outcomes to more of a clinical enablement approach. For example, did the program enable members to take part in care management programs, closed their care gaps, and stay engaged in their health? For example, for a member with diabetes, tie food insecurity with insulin and part D subsidy. Was there an impact on insulin usage and impact outcomes

Connect with us to learn about our comprehensive technology-based platform that can help you successfully implement whole-person care management programs and supplemental benefits to support the holistic needs of your high-risk, high-need members.