In the midst of metropolitan Minneapolis-St. Paul, surrounded by the rich farmland of the Midwest, lurks a food desert, believed to be the fifth largest in the U.S. Metro residents lack access to adequate and inexpensive supplies of fresh fruit, vegetables and other “whole” foods.
That leads to poor eating habits, particularly for those prone to chronic health conditions, such as diabetes. These populations also are likely to delay treatment and consume more healthcare resources.
These problems weren’t of immediate concern to health plans—until recently. More insurers are covering lives of those on Medicare and Medicaid, and taking on more risk in the process. Minnesota plans saw the linkages between poor nutrition and poor health, and began to look for ways to bring better food to the area.
One initiative pairs UCare—an independent, not-for-profit health plan—with the Amherst H. Wilder Foundation, a not-for-profit organization in Saint Paul, to create the Twin Cities Mobile Market. The program took two retired metro buses, stocked them with food it bought at cost from a grocery store chain in the area, and developed a grocery store on wheels program to bring food into the area. The organizations identified 24 locations in the metropolitan area for the buses to sell food, and last year serviced 18,000 residents in the community. UCare is a partner in the program, called Twin Cities Mobile Market.
Assessing Social Determinants
This is just one example of how health plans are paying attention to many factors now understood to impact health. Widely known as social determinants of health—crucial keys such as access to transportation and food, isolation and loneliness, lack of family or caregiver support—these factors are believed to impact as much as 80 percent of a person’s health, far more important than care delivered after illness occurs.
Under value-based care arrangements, health plans now are taking on more risk for members’ overall health and care costs, and that’s why social determinants of health (SDOH) has become a topline concern for insurers. And making an impact on these determinants will depend on health plans ramping up their use of information technology, such as analyzing claims, integrating sources of data and delivering less expensive care alternatives.
It’s not just insurers who have gotten religion on SDOH. Healthcare providers are taking notice, and the population of the U.S. more broadly is beginning to grasp how factors other than hands-on healthcare lead to better health.
One-third of Americans are grappling with stress tied to meeting their basic human needs, such as stable housing, adequate food and reliable transportation, according to the results of a new national survey from Kaiser Permanente released in June. The survey, Social Needs in America, also found that Americans overwhelmingly want healthcare organizations to be involved in identifying and addressing these non-medical social needs.
The survey findings reveal that Americans are experiencing unmet social needs at significant rates. In fact, 68 percent of Americans surveyed reported they experienced at least one unmet social need in the past year. More than a quarter of those surveyed said that an unmet social need was a barrier to health, with 21 percent prioritizing paying for food or rent over seeing a doctor or getting a medication.
“At Kaiser Permanente we think holistically about health, which includes medical care and other factors like access to food, transportation, and housing,” said Kaiser Permanente chairman and CEO Bernard J. Tyson. “By helping close the gap on social needs, we have an opportunity to advance the health of communities across the country and safeguard everyone’s right to thrive.”
That message hasn’t been lost on other health plans. At the recent annual conference of America’s Health Insurance Plans (AHIP) this past June, the impact of SDOH was front and center at nearly every educational session or vendor meeting.
Beyond that, AHIP is starting an initiative intended to gather and enable the sharing of approaches that address these social barriers to health and long term well-being. The program, called Project Link, “aims to make these efforts scalable, sustainable and measureable, with the hope to diminish long-term costs,” said Matt Eyles, president and CEO of AHIP.
A 2018 survey by Change Healthcare found that 80 percent of health insurance plans now integrate social determinant initiatives into their programs. It’s a key reason why AHIP’s board of directors has charged the organization with focusing on addressing social barriers “as an essential part of the industry’s long-term vision for improved health and financial security for everyone the industry serves,” according to an announcement on the program.
Project Link is a key to the effort, says Rashi Venkataraman, executive director of prevention and population health for AHIP. SDOH initiatives that health plans have executed show the need for personalized approaches to overcome barriers to care. “There is no one-size-fits-all approach that will work for all health insurance plans,” she added.
For example, CareMore Health, a Cerritos, Calif.-based organization, has started a Togetherness program for more than 1,100 patients whose clinical records suggest that they are socially isolated, said Robin Caruso, a licensed social worker and Chief Togetherness Officer. Social isolation and loneliness have been demonstrated as having negative impacts on health, and the CareMore program uses care managers to intentionally reach out to those patients and get them connected to healthcare, as well as the community at large, Caruso said.
Caring for Members
The broad interest in SDOH by a wide variety of health plans seems to run counter to the belief that health insurers haven’t cared about initiatives that would bring long-term improvements to the health of members, because those members might be in different plans by the time their health improved, and so a health plan wouldn’t derive benefits from investments in members’ long-term health.
However, the current reality of healthcare has changed all that. For some health plan member segments, plan switching rarely occurs, such as for populations in Medicare Advantage plans or those who are Medicaid dual eligible. Health plans are upping services to employer groups, working hard to retain contracts. The name of the game is getting and keeping members. In these scenarios, it pays to pay attention to factors that demonstrably impact health over the long term.
Payers are working with providers to better incorporate SDOH into care. One project pairs the American Medical Association, the nation’s largest physician organization, with Minnetonka, Minn.-based UnitedHealthcare, part of UnitedHealth Group. The partners plan to work together to better identify SDOH issues that prevent better access to care and hinder patient outcomes.
The project will build on work initiated by UnitedHealthcare to standardize how data is collected, processed and integrated regarding critical social and environmental factors that contribute to patient well-being. SDOH factors that play into patients’ health status include nonmedical issues such as food, housing, transportation, and the financial component that enables payment for medications, utilities and other services.
In another initiative, the Blue Cross Blue Shield Institute—a subsidiary of the Blue Cross Blue Shield Association—is forming a “disruptive business alliance” with Solera Health, an integrated benefits network company, to determine how best to act upon social determinants of health.
“Health outcomes we’ve long known have been affected up to 80 percent by SDOH,” says Brenda Schmidt, CEO of Solera, which helps health plans leverage a network of community-based and digital health solutions. “Prior to (value-based purchasing), the system was not set up to encourage health systems and clinicians to look comprehensively at a patient’s situated context—their socio-cultural, economic and environmental issues that lay beyond the disease state. Now with VBP, we begin to see systemic recognition to address the SDOH.”
But as health plans start to address social factors, they’re realizing the inherent complexity. Effectively delivering needed services that bolster health required nuanced analysis, while putting an emphasis on advanced information technologies, such as population health management and analytics.
Effectively dealing with SDOH will require health plans to draw information on members from new sources, such as social agencies and government programs, putting a premium on information exchange.
For example, Geisinger Health System and its health plan, Geisinger Health Plan, are working together to advance healthcare through the use of the organization’s Keystone Health Information Exchange. Previously, health plans have not thought extensively about the use of HIEs, but that’s changing, say executives at Geisinger. With value-based care growing, healthcare providers and organizations across the continuum strive to find ways to improve care while holding costs down. As evidence of this trend, Pennsylvania has indicated it wants to close care gaps for chronic conditions and is encouraging healthcare organizations, including health plans, to participate in HIEs.
Geisinger Health System founded Keystone Health Information Exchange (KeyHIE) in April 2005. Today, KeyHIE offers a wide range of services to 179 unique member organizations across the area. Geisinger Health Plan (GHP) became a member of KeyHIE in 2011, and uses the HIE’s services to close care gaps; access real-time patient data; receive real-time notifications of admissions and discharges from emergency departments and acute settings; and to access real-time test results, according to Kim Chaundy, senior director of operations for Geisinger.
“KeyHIE believes that health plans are just as important to delivering quality healthcare as physicians, hospitals and other providers,” she says. “Health plans are starting to understand HIEs can be the conduit for efficiency and how we can parse the data,” she says. “They see the value of it.”
Health plans are also turning to a variety of information technologies to meet the cost and quality imperatives inherent under value-based care.
For example, Premera Blue Cross, a leading health plan in the Pacific Northwest, is partnering with Cardinal Analytx Solutions, a predictive healthcare analytics company, to use predictive analytics and machine learning solutions to identify and reach out to potential high-risk customers.
Premera initially partnered with Cardinal to participate in the design and validation of the first version of Cardinal Analytx’s Cost Bloom predictions and medical action plans using proprietary, leading-edge machine learning algorithms. After success piloting this solution, Premera is deploying the solution along with additional risk prediction models it helped to design.
In another use of technology, BlueCross BlueShield of South Carolina is offering Blue CareOnDemand, through which members can access care via a computer or mobile device. The plan was one of the first to write medical policies around telemedicine, says Raad Joseph, senior vice president of the plan.
“We’ve more than doubled utilization rates from 2017 to 2018,” he notes. In 2018, the Blues plan began offering virtual behavioral health services for its accountable care organization and self-funded clients. “We already are seeing 15 percent higher visit volume January to April of this year, than all of 2018,” Joseph noted.
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