Industry Voices—Why payers must address upstream community needs

Health insurance, pen and stethoscope
By being proactive and using predictive models that target the most at-risk populations, payers can identify members who need help and intervene. (Getty/Minerva Studio)

Our nation’s response to the COVID-19 pandemic has taught us, among other things, that systemic racism doesn’t just lead to disparities in food and housing, but in healthcare as well.

Any conversation that includes the identification and elimination of barriers to health needs to include race, especially since it goes hand-in-hand with social determinants of health. Ignoring or glossing over these challenges is the equivalent of putting bandages on a broken bone.

It’s reactive and ineffective. A proactive approach is required.

For insurers, that means combining insight from observed (passive) and self-attested (active) risks to get a clearer picture of their members’ needs and risks so impactful interventions can be implemented that will promote wellness over sick care.

Flattening a different curve

Being proactive means reaching out to a community’s most vulnerable, at-risk populations first, which can’t be accomplished until those groups are identified. There is a hesitancy to use race for predictive modeling, which doesn’t make sense because these models need to be steeped in the real world. And in the real world, race matters.

This can be seen in a study conducted of the Medicaid population in Minnesota using the Carrot Health Social Risk Grouper (SRG), which predicts the risk of adverse outcomes as a result of SDOH. The SRG scale runs from 0 to 99. The higher the number, the higher SDOH risks pose to an individual’s health.

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The study found a striking disparity between Black and white Medicaid members. Roughly 50% of Black adults scored an SRG between 80-99—way above the state’s average of 4% in that range. By contrast, just 7% of white members had an SRG that high. The findings further suggested that SDOH isn’t simply a matter of income. Among the more affluent Medicaid members, roughly 42% of white adults had very few SDoH compared to just 11% of Black adults.

Identifying the barriers to a healthy lifestyle is the first step toward eliminating them. For example, a key SDoH is loneliness, which results in a 60% increase in emergency room visits, 42% more prescriptions and 40% increased spend per member, per year. Providing companionship to those suffering from loneliness will help keep people healthy while driving down costs and alleviating some stress from our overworked healthcare system.

Access to the numbers allows us to get into these communities, see where these disparities occur and do our best to bridge the gap.

Reaching out to those most at risk

Accessing the right data is a sound and effective way for insurers to make sure their members are receiving the help and resources they need to achieve optimum health. Health Allegiance Plan of Michigan, which serves 78,000 Medicare members, was concerned about how the COVID-19 pandemic was affecting their members and exacerbating their underlying SDOH, such as loneliness, especially when the country went into lockdown in the middle of March.  

To get in front of any downstream health outcomes, HAP wanted to understand and proactively address their members’ challenges. Doing so meant focusing on those members who were facing the greatest risk and, therefore, would benefit most from an immediate intervention.

The challenge for HAP was that traditional data measures such as claims history wouldn’t be effective in identifying emerging SDOH risks. This sort of intervention required a predictive model that would allow HAP to get out in front of problems.

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They accomplished this by utilizing the SRG and the COVID-19 Critical Infection Risk Dashboard to identify their most vulnerable members. Armed with this knowledge, HAP then implemented a program with four key objectives:

  • Identify the top 10% of members with SDOH-related issues
  • Outreach to those patients via care coordinators
  • Educate members on relevant personalized topics, e.g. improved hygiene practices
  • Fulfill members’ needs to help impact positive health

Realizing the importance of reaching out to its most vulnerable members first, HAP segmented the 10% of members who would benefit from a targeted outreach into four categories of risk and tailored a level of outreach for each group. The higher the risk, the higher the level of outreach.

Of the 7,676 members who were at a high enough risk to require telephone contact, 42% (3,266) were successfully reached. Using the SRG to match the right members with the right resources—such as masks for those who could not otherwise afford them—HAP was able to enroll 58 of its higher-risk members into other programs.

Fixing the system

When it comes to healthcare, the U.S. does things backward. We are more concerned with treating the sick than we are with keeping people healthy. Fixing this requires identifying and breaking down social barriers that are in the way of people leading their best lives.

By being proactive and using predictive models that target the most at-risk populations, especially those who suffer from racial disparities, payers can identify members requiring the most assistance and intervene before adverse medical outcomes occur downstream.

Anything less is simply patching up the problem instead of fixing it. These barriers and disparities must be eliminated—permanently.

Kurt Waltenbaugh is the CEO of Carrot Health.