Medicaid and the Social Determinants of Health

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: exploring new ways to improve public health and stewardship of Medicaid dollars—

DEBORAH FOURNIER:
More and more programs are coming to the conclusion that the best way to trim their costs is to get out of these larger issues.

JOHNSON:
—the discussion about states making the connection between Medicaid and social determinants of health for improved health outcome.

FOURNIER:
There are a good number of states that are very interested in this, and they are putting real resources, time, and people into this.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we discuss the most pressing public health issues facing our state and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

Today, we examine the opportunity to improve Medicaid programs through the application of the social determinants of health—things like housing, education, transportation, employment, and nutrition.

Medicaid was born in 1965; 53 years later, this program for low-income adults, people with disabilities, children, seniors, and others serves more than 74 million Americans. States and territories looking to improve health outcomes for their citizens lately have been thinking of ways to leverage opportunities in Medicaid financing and service delivery against their biggest public health challenges.

Deborah Fournier is an attorney and a former state Medicaid director. She's currently the senior director of Clinical to Community Connections within the Center for Population Health Strategies at ASTHO. We began the conversation with this question.

Do states often consider Medicaid and the social determinants of health in the same sentence?

FOURNIER:
No, I don't think so; and, in fact, there's only I would say recently been a wave of, or a trend, in Medicaid to really start paying attention to the social determinants of health. Public health directors or state health officials think that we are likely operating our healthcare delivery system backwards. We're treating symptoms that, in large part, are directed or emphasized because of other conditions that exist far outside of a clinical delivery system.

But I'd say in the last five years—three to five years—there's been a very big interest on behalf of Medicaid to start really paying attention to social determinants of health. And some of that is driven by these systems are starting to consider payment delivery systems that focus on outcomes rather than on which individual medical services were provided, and that creates incentive to create new models of care that are more patient-focused.

And those things together have really resulted in Medicaid realizing in many states that it needs to really focus on and begin to address the social determinants of health from among its members.

JOHNSON:
So, is Medicaid driving it or are the states doing that?

FOURNIER:
The states are doing it. Medicaid is in a partnership initiative called the Accountable Health Communities in which it is taking the folks in Medicaid who are really the most complex and fragile—they're called the duals, the dually eligible. So, these are people who, because of their age and their poverty and/or their level of disability, that they qualify for both simultaneously the Medicaid program and the Medicare program.

And so, they are doing an initiative in a number of states—I'm want to say it's about 30, 32—in which they are examining whether screening for and addressing the social determinants of health of these very high risk members or high need members will be effective in addressing their larger health-related social needs. And I think the idea is that, potentially, then will that help to lower their overall healthcare costs.

But states are under no mandate from CMS to take this on. And I really think it's about, like I said, payment reform and different delivery models like ACOs—accountable care organizations—really driving Medicaid to almost an inevitable conclusion that, if it's really going to address these root causes of poor health outcomes and high healthcare costs, it has to look beyond the immediate crisis or event that's driving someone to interact with the healthcare delivery system and address a larger issue that's keeping them from moving beyond that particular condition.

JOHNSON:
Well, it seems like trying to reduce the spending on Medicaid, or at least make it more efficient, is kind of like the quest for the Holy Grail, right? It's been going on forever. The Medicaid is 53 years old—and I was born in the year Medicaid was created so that's exciting for me, I'll never forget that fact now.

But what makes this idea—this notion of social determinants of health—what makes that idea the one? Is that going to finally help us get our hands around that grail, do you think?

FOURNIER:
So, I'm a true believer. I think it will.

And yes, Medicaid is always looking to manage costs. But this is, I think, an unusual time in that Medicaid is trying, is attempting, to address these underlying issues that if they are addressed, you know, there's hope that in 10 years or 15 years, that then it isn't just that individuals have improved, but that an entire population of people has better health outcomes and, as a result, lower healthcare costs.

I mean, we also live in a world now where there's so much data and there's so much opportunity to connect all of the different points of data about someone in order to better drive, you know, precision medicine. To a certain extent, in order to really drive addressing their particular needs through a Medicaid program, to be able to do it—in some states—at a very large scale.

And so, it gets at both of those ideas—the triple aim. You have all the three of those ideas: you've improved experience, improved outcomes, and lower healthcare costs. And this helps—this idea is right in that, you know, right in the bull's eye of that goal, the triple aim.

JOHNSON:
And Medicaid—let's face it—is an insurance program, so they were not born of this notion that you're talking. It really was about, "Send us your receipts and we'll reimburse you."

FOURNIER:
Right, but because now they're being encouraged to not just pay for individual services, but to pay for improving someone's health outcome. They can't meet that goal of improving someone's health outcome unless they in some way address or work with folks who will address, or can address, those underlying social needs that their members may have.

And so, it is definitely beyond the traditional notion of health insurance, "We cover you for certain healthcare services," because more and more programs are coming to the conclusion that the best way to trim their cost is to get out of these larger issues. Because Medicaid actually is a very lean program—has very low overhead and providers are fairly consistent in expressing their concern that the reimbursement rates to providers are not high enough.

So, at some point, Medicaid's programs across the country are starting to look around and say, "Well, we have to do something else differently because we can't necessarily save our way, save our pennies, to get out of the higher cost of care issue that entire country faces, not just Medicaid."

JOHNSON:
Right. We need a healthier population.

FOURNIER:
That's what they're striving for, right? Like, if we can improve someone's overall health, right, and they need to utilize healthcare services less, and maybe they need specialized healthcare services less, and maybe there's just pound-for-pound fewer people that suffer from chronic conditions, right?

So, you know, for example, if you have an entire community of people that live in housing that isn't great, and that the hospitals or community health centers in that area have a wide panel of people who are having to constantly go to the emergency room because their asthma isn't well controlled; there's no link right now for anyone in the clinical medical delivery system to see, "Is there something going on?" Like, are the walls in your home okay. Like, is there mold in there that's constantly exacerbating this? A doctor couldn't know that—why would they, right? How could they?

But for that environment, the environmental condition to be addressed, or if that environmental condition is addressed, then there may be the possibility they add management for not just an individual patient, but maybe a whole community of patients is improved. And that's a reduction of burden on the entire clinical system, right, which is what we all want.

We want folks to be healthier, and we want really responsible stewardship of public dollars, right? We want to make sure that we're using our public funds in the best way we can, and this is a great example, in my opinion, of that.

JOHNSON:
And you've made the case that there are ways to pursue healthcare strategies that can be reimbursed by Medicaid. This is one of them?

FOURNIER:
Well, so there are ways to allow—in certain delivery systems in Medicaid, there are ways to allow health plans to count services like those towards their medical costs, which benefits to them financially in the long run. And there are ways for Medicaid to directly cover case management, for lack of a better word, so that there is robust care coordination for someone who may have a depth of need that goes beyond what, you know, the admin scheduler for a doctor's office can manage, right.

I will say Medicaid can't pay for everything. Medicaid still doesn't pay, you know, room and board. It can pay for services that support someone in obtaining housing and sometimes in maintaining their housing, but Medicaid can't pay rent, right? And it can't build, you know, bricks and mortar structures to house people in. But then you start to get to a point where you're thinking, "Well, who are the other stakeholders that need to be around the table that needed to be contributing?" Because Medicaid certainly can, but there are limitations.

There's a really big federal law that dictates what Medicaid can and cannot do, and so it has to—every state that has a Medicaid program has to abide by those. And like I said, Medicaid programs can help pay for case management, care coordination, and some supportive housing services, but who else needs to be at the table? You know, how are we going to invite folks that maybe represent the community or stakeholders in the community to contribute?

JOHNSON:
In the housing example you mentioned just a minute ago, is there anything there that could potentially be reimbursed by Medicaid?

FOURNIER:
So, the thing—and this is all theoretical on my mind—so there are medical practices across the country that are called medical-legal partnerships that have a lawyer on staff; and through a series of screenings help to identify issues that might be confronting the patient that happened outside of the healthcare delivery system that could be addressed with some legal support.

And I think there's a real open question about can a Medicaid program allow a health plan that delivers the Medicaid services to count the cost of that lawyer working in that practice helping folks to resolve some of these larger issues that affect their healthcare as part of their medical services so that they can get recognized for that expenditure, right? Is Medicaid reimbursing for it—not directly. But is Medicaid employing a health plan that can use those services in the administration of its provision of service—maybe? There's a lot of uncharted territory in this area right now.

You know, we need to be able—you had to be able to collect the data about someone's social determinants of health in order to know how to best address their needs; and there isn't a standardized uniform measure set for the social determinants of health, or one that is used universally by all Medicaid programs, right? So, there is a real need just to get a common alphabet—for lack of a better word—in order to really effectively understand who the folks are that you are dealing with and what their needs are.

And that's where I think public health really comes in. Because, you know, public health has data on the prevalence of morbidities, you know, across a whole range of chronic diseases and conditions and, in some, they have a population-level information about social risk factors.

And putting those two together—you know, especially the social risk factors—if there's a way to marry the data about a population that public health holds with the members that Medicaid knows it has, it might even also lead to more accurate payment for the risk that people present with, right? It might actually lead to reimbursement to the health plans that is more accurate for the depth of need that their members have, which means they are then—hopefully—reimbursed at a level that allows them to put the resources where they need to be for the people who have the deepest needs.

JOHNSON:
Of the states that are engaging, what are they doing?

FOURNIER:
Massachusetts is doing something similar to what I was just talking about. They're using social determinants of health information to improve their risk adjustment.

I think Minnesota is the state that I think is really doing a tremendous amount of work. They have started working on linking social determinants of health data with health expenditures and health outcomes of members so that they can say, "Oh, this social determinant of health is related to, or is a corollary with, this utilization of the healthcare system and this outcome."

And they have, in their Medicaid program, I think they are called integrated health plans. They're like accountable care organizations, and they are now paying them a member rate that reflects the person's social determinant of health risk, their general demographic data, and also giving some incentive dollars for the plan doing appropriate interventions to meaningfully engaged that particular client.

But there's, you know, a number of states are including social determinants of health in there in their quality strategies.

Michigan is using community health workers to collect the social determinants of health data on tablets. They arm the community health workers with tablets. And so, the community health workers, at an individual patient level, then can collect that information for Michigan.

And there's a lot of work that happens around evaluating performance and quality around the social determinants of health in some Medicaid programs, which can be a little thorny, but definitely presents some opportunities as well.

JOHNSON:
Are there any results from those early efforts?

FOURNIER:
Nothing that I can find just yet, but I—like, for example, Minnesota, they're on 2.0 version of their integrated health plans. They just started their work on the social determinants of health with the new payment plan just this year, in 2018. So, you know, it'll be well worth it to see where they go.

And as well with Massachusetts, who also has only recently initiated these types of interventions, which makes sense based on what they are trying to address and is also frustrating, right? We all want to know what works so that we can get to it.

And at the same time, in order to improve someone's health outcomes, it's more than just taking a pill, right? It's the aggregate result of addressing these larger issues that we now know have this tremendous impact on someone's overall health status and health outcome.

So, we have to start baseline somewhere before we can see whether or not there's been an improvement. And I think we're in those just nascent stages of—we've established baseline, now we're going to see if we've done any good.

JOHNSON:
Of the states not pursuing these sorts of strategies, is there a reason why?

FOURNIER:
I don't think there's a uniform reason why. I think states are busy and there's always something—you know, there's always Zika or Ebola or a hurricane—you know, there's always something coming up. And I would imagine that every state wants to do this, but time and resources, time and people, and this requires that because it requires a lot of collaboration across sectors, right?

These sister agencies working together to identify what they want to measure and track and what they think is effective in doing so—you know, that takes a lot of coordination. And then, just tracking the actual work and seeing what the results are—it's not a small effort.

JOHNSON:
There is no fear or concern over being reimbursed for things that they're doing, is there?

FOURNIER:
I think figuring out how to sustainably finance the social determinants of health is definitely the threshold issue.

But again—as states start to pay for healthcare differently, and they start to think about what contributes to health differently, and then they start pursuing this—I think the challenge is Medicaid cannot pay for everything on its own, just by dent of the structure of the program. And so, it's trying in many jurisdictions to do with what it can within its lane to address these issues and see where it gets.

JOHNSON:
The best argument for marrying your social determinants of health with your Medicaid programs?

FOURNIER:
It is effective, smart use of public assets in a public program for residents of a jurisdiction, right? And we want to make good use of our public dollars. And if we can actually address a way to improve someone's health outcome, right, and the conditions that really affect that, then we stand to lower morbidity, comorbidities—maybe even mortality, or improve mortality's rival rates—if we can get there.

So, it's like, it's the good, it's the right thing, and it's the smart thing to do at the same time. But we're going to get good health out of it, and it's an effective use of the public resources and public assets that we've already invested in.

JOHNSON:
Let's pretend we've got an appointment for another discussion on this issue two years from now. Based on what you know today, what will that conversation be like?

FOURNIER:
I think that conversation will be like, how do states mimic what has been successful in Kansas and Michigan and Minnesota and Massachusetts based on what they found out? How are they—how do the different Medicaid programs use what those states have learned? Who are at the vanguard, at the front of the charge, in their own programs?

How long will it be until we feel like we have adequately addressed these sort of baseline concerns, baseline needs, so that we don't have to keep retreading the same water over and over and over again?

JOHNSON:
I'm an old DJ, so many things that I bump into daily remind me of songs; and you've mentioned Kansas—Kansas has a song called "Point of No Return."

Is that where we are on this? Is this happening one way or the other, eventually?

FOURNIER:
I don't know that that's true.

Medicaid is really driven by state policy priorities. I think there are a good number of states that are very interested in this and are putting real resources, time, and people into this; and I think to a certain extent because the literature is clear, because it's not something we can walk away from now and say, "Well, we don't understand why that was happening"—we do.

How it unfolds, how the states choose to address this, whether they choose to address it—I think that's also up in the air. But for those states that are pursuing it, I'm excited to see what they find out.

JOHNSON:
For more information about Medicaid strategies to improve public health, visit the ASHTO website. The link to these resources is in the show notes.

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This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.