By Monica E. Oss, Chief Executive Officer, OPEN MINDS
We have decades of research showing how lack of social supports drives health care spending in the U.S. changed these to items in our library. But there have been some massive policy impediments standing in the way of using any “health care” resources to address these issues.
Thankfully that trend is starting to reverse. A few years ago, The Centers for Medicare & Medicaid Services (CMS) changed the rules for Medicare Advantage plans, allowing them to address member social support needs. (For a great example of this, check out the keynote by Stephanie Franklin, MPS, Director of Population Health for Humana, What, When & How To Share Data – Innovating For Social Needs & Population Health Strategies, at 2022 OPEN MINDS Technology & Analytics Institute.) And just in the past few months, CMS has approved a number of state Medicaid waiver requests to pay for coverage of health-related social needs. Some of our recent coverage of this trend includes:
- CMS Approves Oregon 1115 Medicaid Waiver Renewal Provisions For Continuous Eligibility, Coverage Expansion & SDOH
- CMS Approves Arkansas Amendment To ARHOME Waiver To Expand Community-Based Care & Health-Related Social Needs For High-Risk Populations
- CMS Approves Arizona Medicaid Waiver For Health-Related Social Needs & Housing
- New York Submits $13 Billion Medicaid Waiver Amendment To CMS With Health Equity Regional Organizations & Social Determinants Of Health Networks
We got valuable insights into what this state-directed shift to integrate coverage of health and social services means for Medicaid beneficiaries last month from Elizabeth Cuervo Tilson, M.D., State Health Director and Chief Medical Officer for the North Carolina Department of Health and Human Services (NCDHHS). In her keynote, Connecting The Dots: How North Carolina Is Creating A Statewide Coordinated Network For Whole Person Health, at The 2022 OPEN MINDS Technology & Analytics Institute, she described the state’s roadmap to improving health by addressing the social needs of state residents, including Medicaid members. Dr. Tilson said there are four factors driving state social service policy—housing, food insecurity, stress/violence, and transportation. The state is managing two related initiatives simultaneously—a statewide social service initiative for all citizens, NCCARE360, and a series of Healthy Opportunities pilot programs within the Medicaid plan.
NCCARE360 is a statewide system using shared technology to assess for and identify residents with unmet social needs—and then refer those people to the appropriate community programs. The system is available and being used for all populations in North Carolina, not just for those covered by Medicaid. Dr. Tilson observed, “A lot of times when we talk about social drivers, people immediately say, ‘Oh, this is a Medicaid problem’. And there is a stigma attached to that issue. This is not a Medicaid problem. Blue Cross Blue Shield in North Carolina are doing a lot of work on food security, and they looked at their plans and 30% of their members are food insecure. Get it out of your head that this is only a Medicaid problem, it isn’t and the more we can scale and align across all of our payers and our uninsured populations, the better we are.”
The system is a public private partnership between NCDHHS and the Foundation for Health Leadership and Innovation. The implementation partners include United Way of North Carolina, 211, and Unite Us. The platform includes a robust resource directory, a closed loop referral system, care navigators, and community engagement managers. The program is live across North Carolina, has 2,900 participating community-based organizations, has served over 25,000 people in the past year and more than 100,000 since the program’s inception in 2019. In the system, food assistance and housing assistance were the most frequently requested social support needed, at 27% and 23% respectively. At this point, there is no additional reimbursement for provider organizations that refer people to social services or to the social service organizations accepting those referrals as part of the core statewide platform.
The Healthy Opportunities Pilot program takes the social support concept to the next level. North Carolina’s 1115 Medicaid transformation waiver authorizes up to $650 million in state and federal Medicaid funding for the pilot program for five years. Pilot funds will be used to pay for 29 evidence-based, non-medical services. To qualify for pilot services, Medicaid members must live in a pilot region and have two or more qualifying chronic conditions and at least one social risk factor meeting the North Carolina definition. The Medicaid health plans are paying for the qualifying social services within the program from funding outside of their capitation payments.
The Healthy Opportunities Pilots have a structured process to link people to services to health plan payment. “The care manager works with the patient to identify a food or housing need, and they send the referral in the platform that goes to the prepaid health plans and managed care organizations,” said Dr. Tilson. “The plans approve patient eligibility and authorize services because ultimately the plans are going to be paying. Once the plan has approved eligibility and authorized services off, that referral then continues to the human service organization. The human service organization then delivers the service. The service is documented and at the same time an invoice is created in the platform. That invoice then comes back to the network lead, they do some Q&A just to make sure all the invoices look like all the I’s are dotted and the T’s are crossed. And then the plans receive the invoices and make payments directly to the human service organizations.” From Dr. Tilson’s perspective, these initiatives are initial steps in determining what works best in supporting people’s social service needs. “Our goals are certainly to improve health outcomes, to promote health equity, to reduce health care costs, but also a really important piece is learning,” she said. “I don’t think we need to learn that food is important for people’s health, I think we need to learn exactly what are the risk profiles of the person and what’s the right combination of social services. And what’s the right dose, and what’s the right frequency, and let’s really narrow it down so that we can think about investing in this going forward in a more efficient way. The learning component is important because want to be sure that we have an accountable and a sustainable system and sustainable payment vehicles. This is our chance, our collective chance to do things with incredible intentionality and accountability.”