Medicaid ACOs Experiment with Social Determinant Requirements
State governments are experimenting with requirements and incentives for Medicaid accountable care organizations to address social determinants of health.
Government executives say Medicaid ACO programs offer several key leverage points for addressing disparities and social determinants, including partnership and care management requirements, quality metrics and financial incentives. Here are some examples of efforts under way:
• Starting in March 2018. Massachusetts plans to measure ACOs on social service screenings, as well as use of state certified “community partners.” Massachusetts also will risk-adjust ACOs’ rates and cost targets based on social determinants including stability of housing status and “neighborhood stress score.”
• Rhode Island requires screening for and addressing social determinants of health. It has established certification requirements for participating accountable entities to demonstrate capacity and capabilities in addressing social determinants. And its Quality Scorecard includes 10 required measures, one of which is a SDOH Measure.
• Colorado requires contractors to establish relationships with community-based organizations.
• Oregon encourages contractors to provide services to address social determinants, such as a member’s living environment.
A Feb. 14 webinar put on by the Center for Health Care Strategies Inc. featured a presentation by Mathew Spaan, manager of care delivery and payment reform for the Minnesota Department of Human Services.
The participants in the Minnesota Medicaid ACO program are called Integrated Health Partnerships (IHPs). The program began in 2013 with six IHPs. It has grown to 24 IHPs, covering more than 460,000 beneficiaries. In 2018, the state is launching its “IHP 2.0” model that seeks to help the IHPs address social determinants.
“Because we have had the model in place for a few years, we felt it was important to evaluate successes and challenges,” Spaan said. He explained that IHP 1.0 did have successes — $213 million in savings across all participants, with reductions in emergency department visits and hospital stays. “This was positive but not sufficient to move us in right direction,” he said. “It let us have the social capital and backing to make the tweaks we wanted to make.”
For both the IHPs that were taking on shared risk and those that weren’t, Minnesota has added population-based payments to the model as it adds more robust data and technical assistance. “We want to widen the focus of health and care beyond the simple medical model,” Spaan explained. “We are adding metrics into the mix we didn’t have before.”
In the application process to become an IHP in the new program, those applying must show certification that they are an ACO or a patient-centered medical home. If they don’t have those, there is more work in demonstrating they have similar capabilities and experience. They must show they have EHRs, work flows and care coordination capabilities. They also must have either formal or informal demonstrated partnerships with social service agencies.
In terms of incentives, the population-based payments are tied to measures related to both health equity and clinical metrics. “That suite of measures is tied to interventions that are largely idiosyncratic to the area, so rural Minnesota has different populations than urban areas,” he said.
“The third lever involves what we can do for the IHPs to enhance models to be successful in what they do in addressing social risk factors,” Spaan said. The population- based payment is based on the clinical or medical risk of the attributed population as well as a social risk factors quotient determined by the Department of Health.
The department has studied the predictive quality of the risk factors, and what it suggests for the total cost of care for that patient. “We worked with our actuary to identify the predictive value of factors in addition to clinical factors,” he said. If a social determinant increases the expected costs, it moves those patients up the risk ladder, and they earn more per member per month for population-based payments paid quarterly.
Spaan said the state is providing the IHPs data at the aggregate level (and in some cases on the individual level, if legal) on how many people are dealing with housing instability, food insecurity, substance use issues, or deep poverty. “We worked with the Department of Justice to get prison data. We are working to get county jail data. We have heard county jail imprisonment may have a greater impact than prison.”
“We see this focus on social determinants of health as the beginning and not the end,” Spaan said. “We anticipate we will continue to refine factors and monitor and evaluate the arrangements with ACO partnerships to see how we can push the envelope.” He said the state needs to ask whether these are the right determinants to look at and is focusing on them having an impact in terms of making citizens healthier.
