The Social Determinants Opportunity

By Monica E. Oss, Chief Executive Officer, OPEN MINDS

The past week we’ve seen a blitz of new research on the effects of social determinants and lifestyle on health. Processed foods appear to cause cognitive decline. Exercise appears to delay dementia. Diet has been tied to depression. People with housing have been found to be better able to manage their diabetes.

The link of social determinants and lifestyle to health care costs is not new. And payers are taking notes. Most recently, there are the requirements to address SDOH under new Medicaid managed care contracts in a number of states including North Carolina, Louisiana, and Iowa. Not to mention the major overhaul in California with the transition to CalAIM. And, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for inpatient and long-term hospitals to better document SDOH.

On the health plan front, Kaiser is doubling its SDOH investment to $400 million. Humana, UnitedHealth Group (UHG), and Blue Cross Blue Shield are also making big investments in SDOH. Most recently, AmeriHealth Caritas, which operates Medicaid managed care plans in 13 states and the District of Columbia, launched a new wholly-owned subsidiary called Social Determinants of Life that will invest in, support, and deploy services focused on SDOH. UnitedHealthcare (UHC) launched Community Catalyst, a community-based initiative to address health equity and promote positive health outcomes for Medicaid beneficiaries.

But how do provider organization executive teams take advantage of this wave of interest? That was the focus of The 2022 OPEN MINDS Performance Management Institute session, Generating New Revenue With Social Support Programs: Design, ROI Estimates, & Contracting, featuring James Stewart, President and Chief Executive Officer at Grafton Integrated Health Network and OPEN MINDS Executive Vice President Kim Bond. There are three ways to improve revenues and/or margins by adding social support programs—increased referrals, increased performance bonuses, and increased revenue from new service lines.

Increased referrals—For many specialty providers organizations, assessing for social support needs and providing referrals to social supports can address a ‘pain point’—and result in more referrals. Finding the answer means conducting a feasibility analysis to determine the cost of the additional program modifications and the additional revenue expected—and getting a commitment from payers of their interest. Adding these services also has the opportunity to provide increased exposure to new segments of the community—for example addressing housing or food insecurities can connect provider organizations with community groups and consumers which can drive behavioral health referrals.

Increased performance bonuses—Adding SDOH to any existing service carries the potential to improve outcomes and reduce costs—which are common metrics in value-based contracts. The key is to take a focused look at all of the investments required to achieve enhanced performance metrics—and the value of those additional payments. 

Increased revenue from new service lines—Designing a new service line that incorporates specific social supports for specific populations is a diversification opportunity. But it needs the same discipline in analysis and execution as designing any new service line.

The question for provider organization executive teams is where to go with this opportunity. Done well, this can bring provider organizations more revenue in the form of better rates and more contracts with health plans—especially if they can combine value-based care with whole person care. Done poorly, provider organizations will miss the window where payers are open to finding more service solutions that account for SDOH. The time to act, for many executives, is now—but the key will be acting with forethought, care, and a solid plan for return on investment.