Posted: 26 Mar. 2019 7 min. read

Want to improve the health of Medicare/Medicaid members? Meet their socioeconomic needs

By Sarah Thomas, managing director, Deloitte Center for Health Solutions, Deloitte Services LP

Consumers are driving change across all industries, and health care is no exception. To keep up, many health plans and health systems are looking beyond the immediate health needs of their members and patients and are taking steps to address issues related to where they work, where they live, what they eat, how they get around, and other factors that can affect their health. Health care organizations that understand how social determinants of health (SDoH) affect consumers could gain an advantage over their competitors—especially when competing for Medicaid contracts—while also working to drive down health care spending and improving the health of individuals and their communities.

A focus on SDoH can help health plans and health systems become proactive (rather than reactive) when serving their members and patients. Screening and directing people to community resources is where many health plans (and health systems for that matter) are starting. But some are figuring out ways to offer services. A Medicaid managed care plan, for example, could create a low-cost meal service that delivers healthy food to its members with diabetes. A local hospital might connect its elderly patients to ride-sharing services to ensure they don’t miss important appointments, or to prevent them from relying on ambulances for non-emergency care.

Work on SDoH has evolved a lot in just two years

It has been two years since we surveyed hospitals to find out how they were identifying and reaching out to people who could benefit from services that connect them to housing, healthy food options, and reliable transportation. This year, we interviewed executives and leaders from 14 managed care organizations and Medicare Advantage plans to learn what they were doing to address social needs among their Medicaid and Medicare members. We also interviewed leaders from four states to find out how they are supporting SDoH efforts.

Since we published our first SDoH paper, a number of startups and technology vendors have emerged to help health systems and health plans identify people who could benefit from SDoH services and/or help connect them to a network of service providers, and then evaluate the effectiveness of the interventions. Meanwhile, the US Centers for Medicare and Medicaid Services (CMS), along with some advocacy groups, are offering new tools to screen for SDoH. For example:

  • Organizations such as NowPow and TAVHealth provide information about—or connect individuals and health care organizations to—community groups.
  • Some groups have launched screening tools, such as CMS’s accountable health communities (AHC) instrument, and the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) from the National Association of Community Health Centers.12
  • Technology companies have developed care coordination tools. Unite Us, for instance, builds coordinated care networks of health and social service providers to help improve patient outcomes.

Some states require SDoH for Medicaid participation

While a growing number of states are using Medicaid Section 1115 waivers to implement work requirements, that same waiver authority can be used to address a wide range of social needs for Medicaid beneficiaries. States also could add SDoH requirements to their requests for proposal. Massachusetts, for example, now requires accountable care organizations (ACOs) to screen for SDoH needs and measure their performance on a host of related quality measures. Under the Delivery System Reform Incentive Payment (DSRIP) program (a mechanism within the broader 1115 waiver), Massachusetts covers services related to housing and nutrition for Medicaid members who meet its health needs-based criteria.

Similarly, North Carolina requires contracted Medicaid managed care plans to screen all members to assess SDoH needs (e.g., food insecurity, lack of stable housing and transportation, and exposure to interpersonal violence). Health plans are required to connect those members to resources in the community that can provide help. The state is implementing a multi-directional, cloud-based resource and referral platform to help connect health and community resource providers, and to evaluate how addressing social determinants can reduce costs and improve health.

While technology is making it possible to extend the reach of community services to the people who need them, some health care organizations are working to overcome two significant hurdles:

  • Consistent coding of SDoH: While coding for SDoH has long been a challenge, some health care organizations are developing their own solutions to standardized SDoH coding.
  • Demonstrating return on investment: Some SDoH initiatives have led to better health outcomes among participants. It has been more difficult to demonstrate cost savings.

Four elements health plans should consider including in their SDoH efforts

According to our interviews, health plans are using the following strategies to address the social needs of their Medicare and Medicaid members:

  1. Employing multiple modalities to identify social needs: Telephone, online, and mail questionnaires are the most common methods health plans use to screen members for social needs. However, in-person and in-home assessments are typically the most effective screening methods. Some health plans also use predictive analytics and machine learning to risk-stratify members and anticipate their social needs. Other organizations are adding marketing or consumer data to social and clinical data to glean more information via predictive analytics.
  2. Using one-on-one support to connect members to services: Health plans often consider care/case managers and community health workers to be critical for addressing the social needs of high-risk members. The health plan executives we interviewed said most enrollees with identified social needs are referred to community-based organizations (CBOs)—local nonprofit organizations that work to meet community needs—and other agencies. However, enrollees who are deemed “high-risk” (often due to diagnosis or high utilization) might be assigned a care/case manager or community health worker who can work one-on-one with the enrollee to coordinate services.3 Peer-to-peer programs can help link enrollees to community resources, too.
  3. Establishing strong partnerships through formal contracts and value-based care (VBC) arrangements: For health plans, multi-stakeholder partnerships could be the core of a strong SDoH initiative. A formal partnership that aligns incentives can be the key to success. In particular, VBC arrangements can be critical to maintaining strong partnerships, something we also found in our research on health systems two years ago. Several of the health plan representatives we interviewed noted that increased participation in VBC arrangements among network providers has driven some health plans to invest more heavily in SDoH initiatives and to work more closely with providers on such initiatives. Many health plans see it as their responsibility to help providers succeed in value-based care.
  4. Monitoring and evaluating interventions: Health plan leaders typically recognize the importance of evaluating social needs interventions. However, few say they can do it effectively. This is not just because these programs are new. In fact, several of the health plan leaders we interviewed said they have been addressing the social determinants of health for a decade or longer but haven’t been systematically collecting data or monitoring and evaluating interventions. A shared data platform can help health plans close the loop on referrals and evaluate the impact interventions have on health outcomes, utilization, and spending. At least one health plan is using a multidirectional data platform, which allows it to share data with providers and social services groups using a cloud-based database.

What’s next?

Most health plan executives told us that when it comes to SDoH interventions, they are still learning. However, they know that now is the time to experiment with new approaches that can contribute to the SDoH evidence base and hone their business cases. Some are considering experimenting with technologies—such as mobile apps and virtual care—while maintaining one-on-one support programs for high-need and high-risk members. Many executives said they are interested in adopting data platforms to share information and evaluate interventions more easily. But they also agree that they need to overcome significant technological and operational challenges before they can get there.

As SDoH innovation and maturity continues, health care stakeholders should continue to coordinate efforts, keep abreast of new evidence and tools to incorporate into programs, and ensure that SDoH efforts remain patient-centered and integrated into patient care. Two years from now, I hope that we have great evidence that guides more investment into this important area.

1. US Centers for Medicare and Medicaid Services (CMS), The Accountable Health Communities Health-Related Social Needs Screening Tool
2. National Association of Community Health Centers, Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
3. “Standardizing Social Determinants of Health Assessments,” Health Affairs Blog, March 18, 2019


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Sarah Thomas

Sarah Thomas

Managing Director | Center for Health Solutions

Sarah is the managing director of the Center for Health Solutions, part of Deloitte LLP’s Life Sciences & Health Care practice. As the leader of the Center, she drives the research agenda to inform stakeholders across the health care landscape about key trends and issues facing the industry. Sarah has more than 13 years of government experience and has deep experience in public policy, with a focus on Medicare payment policy.