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

Thanks to the input from state governments, many Medicaid managed care organizations (MCOs) now include provisions about social determinants of health.

But neither those governments nor the federal government fully clarify how MCOs can address them, according to a new report (PDF) from The Association for Community Affiliated Plans.

Social determinants of health, like housing, employment and education, have gained increased attention in recent years. Several studies have indicated the outsized importance these factors have on people's health, but the means to improve them obviously fall outside of the traditional healthcare system. This puts MCOs who are contracted to improve social determinants in somewhat of a conflicted position.

ACAP pointed at several section 1115 proposals to show how it can be done. Demonstrations in Massachusetts and Oregon, for instance, created a managed care plan with "flexible services"—non-healthcare-related services—to make sure beneficiaries had a "safe and healthy living environment."

“Social determinants of health play into the strengths of Safety Net Health Plans, as they have found ways to improve their members’ health while containing costs at the same time,” said ACAP Chief Executive Officer Margaret A. Murray, in a release accompanying the report. “There’s a point where common sense takes over from billing codes—for people without stable housing who are leaving the hospital after surgery, it’s far less expensive to offer temporary housing than to wait for them to be readmitted. This is where managed care can offer a superior solution to fee-for-service.”

In its study, ACAP examined MCOs in 40 states, along with 25 approved 1115 demonstrations, to come up with ways federal law can be more flexible when it comes to these types of services. The organization came up with a list of five policy recommendations CMS could implement:

  1. Make it easier for vulnerable populations to access health services and care coordination: By suggesting modifications to 1115 demonstrations, CMS can help make sure this information is front and center to reduce churn in vulnerable populations.
  2. Enhance agency collaboration at the federal level: Currently, interagency coordination on social determinants of health isn't especially common.
  3. Provide additional guidance on how states can encourage and incent MCOs to invest in social determinants: States need more guidance to clarify how plans are allowed to use "in lieu of" and "value added" services to improve interventions on social determinants. ACAP said CMS should provide that guidance.
  4. Approve section 1115 demonstrations that test strategies to address social determinants: In general, ACAP said CMS could approve a greater number of demonstrations that test strategies to tackle social determinants of health.
  5. Support outcomes-based payment for social determinants interventions: ACAP said CMS can guide these payments in such a way that they are being used on proven and successful models for interventions.

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Since managed care came into vogue, most states have filed either a successful 1115 demonstration to enact managed care organizations or a request for proposals to do so. Yet even in approved plans, MCOs often don't know how to provide interventions for social determinants of health.

"While it is now common for state contracts with Medicaid managed care organizations (MCOs) to include provisions around social determinants, many states do not clarify within the contract how MCOs can utilize flexibilities within federal law to address social determinants. And while many states set goals for social determinants in contracts, comparatively few offer payment incentives," ACAP said in the release. 

By providing this clarification, along with other policy fixes, ACAP said CMS could play an important role in enabling managed care experiments across the country.