Why New Jersey's top insurer wants to expand its work on the social determinants of health in 2019

Addressing the social determinants of health requires that payers and providers get into the communities they serve.

That’s the driving factor behind the success Horizon Blue Cross Blue Shield of New Jersey has found in its project in Newark—and why the insurer wants to expand that work to the rest of the state.

The backbone of the social determinants project is a group of personal health assistants, people who live in the local community and serve as liaisons to help the Horizon and its provider partner, RWJBarnabas Health, reach the initiative’s target patients.

Allen Karp, Horizon executive vice president for healthcare and transformation management, told FierceHealthcare that these workers helped to bring cultural gaps and educate their peers on navigating the health system.

RELATED: Why UnitedHealthcare wants to expand diagnostic codes to the social determinants of health

They’re the “quarterback” of the program, Karp said.

“Trust is a big deal,” Jennifer Velez, executive vice president for community and behavioral health at RWJBH, told FierceHealthcare. “Trust is a very looming factor, critical to populations where not everybody engages every day with a hospital system.”

Building the initiative

Karp said that in 2017 the insurer and RWJBarnabas Health came together and agreed to work together to address unmet needs for members in the New Jersey city, most of whom were frequently in the emergency room.

Velez said that the health system saw models that were working globally to address these issues and her team wondered why they weren’t be applied stateside. Coincidentally, around the same time, Rutgers University began to offer training that could kickstart a community health worker program.

RELATED: Philadelphia fell victim to the opioid epidemic. Its largest insurer is trying to save it

The analytics Horizon had at its disposal, the clinical knowhow at the health system and partners in the community made a potent combination, she said.

“It was a team approach,” Karp said. "Payers are sort of in one lane, health systems in another lane. There’re no cross streets, they all kind of go down their own lane. This was a way to bring together those services.”

Other insurers and providers looking to tackle these issues need to build a foundation of leadership that believes in the business case for tackling these issues and also a political climate that’s open to nontraditional approaches to healthcare—which Horizon found in New Jersey, Karp said.

Identifying the patient population

Horizon identified 1,000 members across three zip codes in Newark for the program—40% of which enrolled in the program. These patients would make visits to the ER multiple times a week and were racking up healthcare costs between three and four times what the insurer would expect for its membership, Karp said.

The members in the program trended younger, typically between the ages of 25 to 40, meaning they were very unhealthy for their age. They also often fluctuated between commercial insurance coverage and Medicaid, he said.

RELATED: 5 ways CMS can better address the social determinants of health in Medicaid

For example, one man flagged by the program was not adherent to his medications and was thus making frequent trips for care. However, he wasn’t taking his prescriptions because he had to choose between them and paying rent, Karp said.

In another case, a single mother of three was struggling to manage multiple comorbidities, including diabetes, hypertension and anxiety, but was also unable to find a primary care doctor she was comfortable with, he said.

Velez said that RWJBarnabas applied a similar approach to a program targeting opioid users who visited the ER. The health system has peer recovery coaches who meet with these patients and help identify needs that may be driving their addiction, including social factors like homelessness.

“I believe that community health workers—those natural supports in the community—are really the next generation of healthcare providers,” Velez said.

The results

Since the program launched, Horizon and RWJBH have seen a 25% drop in care costs for this population, and a 24% reduction in visits to the ER. In addition, visits to behavioral health providers increased by 35%, addressing an unmet need, Karp said.

“Identifying those and really understanding what was driving them was critical,” he said.

Data also allowed the program participants to target individual needs within the broader goal of reducing unnecessary ER costs and boosting population health.

RELATED: Why Lyft is making Medicare Advantage a key focus of its healthcare work

In the case of the man balancing rent payments and his prescriptions, Horizon and RWJBH connected him with resources to get him into a rent-controlled apartment, keeping housing costs low, and helped him get back on his medication regimen, including introducing a mail-order option. He hasn’t made a trip to the ER in six months, Karp said.

For the single mom, the program was able to connect her with a PCP and with behavioral healthcare for her anxiety, he said. She also hasn’t been to the emergency department in more than six months.

These successes are driving Horizon, the state’s largest insurer, to seek additional partners this year to expand into new urban areas.

“This is an area of healthcare a lot of people are interested but hasn't really gotten the focus until recently,” Karp said. “I believe we’re in a good position in New Jersey in order to really make a difference in the issues that we’ve come across.”