Leveraging Data to Address the Social Determinants of Health for Medicare Advantage Members

July 07, 2020 – ZeOmega

Like many other healthcare stakeholders, Medicare Advantage (MA) health plans seeking opportunities to improve outcomes for their members are now looking beyond the basics of traditional clinical care and incorporating interventions that address the social determinants of health (SDOH).

Social determinants, such as food and housing security, financial resources, transportation access, and education, have an enormous impact on an individual’s ability to engage with the healthcare system and maintain their wellbeing. They directly affect at least half of a person’s health outcomes, making it extremely important to take a comprehensive, holistic approach to patient care, especially when chronic disease is a factor.

Mitigating the impact of negative socioeconomic circumstances can help to prevent the need for high-cost clinical care – and make necessary care more accessible and effective.

In recent years, payers, providers, regulators, vendors, and community-based organizations have started to work together in a coordinated manner to address these issues, but there is still a long way to go.

(Related reading: ZeOmega Experts Join HHS-CODE Roundtable on Social Determinants Of Health)

Fortunately, Medicare Advantage plans have unique insights into their members and the socioeconomic challenges they may be facing. In this blog post, we will take a deeper look at how MA plans can leverage these insights to support individuals in their communities as well as in the clinical setting.

Understanding the impact of social determinants on the Medicare Advantage population

The effect social determinants of health have on an individual can be difficult to quantify. Historically, healthcare organizations have not focused on collecting structured, standardized data about socioeconomic factors. As a result, providers have found it challenging to identify at-risk individuals and the interventions that may help them overcome their adverse circumstances.

The Centers for Medicare and Medicaid Services (CMS) recently highlighted this problem with a report on the scarce use of Z-codes, the group of ICD-10 codes dedicated to recording known SDOH issues. In 2017, only 1.4 percent of claims for Medicare fee-for-service beneficiaries included Z-codes at all, the report shows. The most frequently used codes were related to homelessness, social isolation, and troubled domestic relationships. About three-quarters of individuals with Z-codes also had a hypertension diagnosis and around half were living with depression.

The report hints at the staggering scale of overlap between socioeconomic challenges and chronic disease among the Medicare-aged population. Approximately 60 percent of Americans experience at least one chronic condition and 90 percent of all health spending goes toward managing the health of these individuals.

Health plans that can design relatively low-cost community-based interventions, such as organizing rides to medical appointments or providing home safety equipment to prevent falls, have the chance to significantly improve quality of life and trim avoidable spending for people struggling with long-term health issues.

MA plans can begin to build the infrastructure to capture and act upon SODH data with an integrated population health management platform that includes tailored, automated workflows for episode-based care management. Plans can also begin to explore recent changes to benefit design regulations that allow MA sponsors to address SDOH issues more directly at little or no cost to the member.

Using data analytics to implement flexible benefits and community programs

In 2019, CMS announced more options for MA plans to offer supplemental benefits that cover non-medical services, such as healthy meal delivery, adult day care, and non-emergency transportation. However, MA plans have been slow to offer these new programs to their members, largely due to financial concerns and uncertainty about how to do so in a targeted and meaningful fashion.

Advanced data analytics and artificial intelligence tools may be able to help create a focused basis for creative benefits and community-based partnerships.

For example, one MA plan serving the Roanoke, Virginia region was able to use their population health analytics platform to identify specific census tracts with higher levels of socioeconomic need. The region contains more than a dozen census tracts, but zeroing in on the three regions with the most complex underserved populations allowed the plan to maximize its resources, reduce unnecessary spending, and see the best possible results.

As local and regional authorities partner more closely with solution providers, healthcare systems, and health plans, these types of data assets are becoming more robust and sophisticated.

With the right technology platform, health plans can unlock unprecedented insights into their members’ socioeconomic circumstances and create highly personalized, impactful interventions to get ahead of disease exacerbation and higher-than-necessary costs.

Integrating coordinated SDOH interventions across the enterprise

After developing a set of benefits or programs to implement, MA plans will need data-driven tools to manage their beneficiaries, collaborate across care settings, and communicate with every member of the care team.

Health plans must collaborate with their partners in primary care and elsewhere to design SDOH programs that complement and enhance one another for maximum efficiency and effectiveness. Plans can gain visibility into these programs with an integrated, interoperable care management platform that includes data from the clinical ecosystem as well as the health plan environment.

A unified, shared care plan allows MA plans to easily see all chronic disease management and SDOH interventions completed for every member at the plan level and the primary care level. Automated, evidence-based workflows can help case managers identify any gaps in care, make referrals, assign new tasks to different team members, easily collect information from members, or trigger follow-up conversations, if necessary.

Taking a coordinated, data-driven approach to managing the social determinants of health will empower MA plans to begin structuring their responses to socioeconomic challenges and analyzing the resulting data to produce new learnings about the effectiveness of their interventions. (Leveraging the Social Determinants of Health: What Works?)

Care management and population-level analytics tools will only become more important for MA plans as they continue to refine their ability to address SDOH. With access to detailed community-level information and enhanced insights into individual members’ challenges, MA plans can take on the crucial task of controlling costs, improving outcomes, and generating truly positive changes for individuals inside and outside of the clinical setting.