Health starts in our homes, continues in our communities, and is largely impacted by our day-to-day choices and interactions. The interconnectedness of life demonstrates why providing holistic healthcare that delivers long term results is hindered by a primarily clinical approach. Instead, understanding how our health and wellness is influenced by how we live, work, play, and behave bears more importance than clinical and genetic factors. The concept of social determinants of health (SDOH), highlighted as a key trend in our recent 2020: Year of Integration Executive Brief, evolved from an industry trend and buzzword to an area of significant focus for all healthcare stakeholders.
Figure 1: Driving Factors of Health and Longevity
Although there are numerous ad hoc solutions making strides toward addressing social barriers, the missing link for sustained success is a convener— an entity that serves as the primary coordinator to unite all the individual efforts of health plans, clinical delivery, community and policy stakeholders in a holistic way. The healthcare ecosystem is the proverbial “the whole is greater than the sum of its parts” and the convener is the thread that stitches together the disparate SDOH players under a shared value proposition to deliver long-term sustainable costs and improved health outcomes. By aligning incentives and outcomes, conveners are responsible for coordinating and integrating coverage, policy, clinical delivery, and community-based resources for a member-centric approach:
The figure below depicts the role of a convener helping coordinate and align roles toward a common consumer centric model across coverage, policy, clinical, and community resources.
Figure 2: Member-Centric Approach of a Convener
Many organizations could play the role of a convener, and this role may vary by community. Payers, health systems, public health systems, and potentially large endowed community-based organizations are all options based on the local market. We believe that health plans are uniquely positioned to assume the convener role and drive alignment across policy, coverage, community, and clinical delivery. Health plans provide the greatest number of touchpoints with the entities above, as well as the capital and long-term value proposition to effectively act as a convener and achieve successful and profitable SDOH programs. Health plans are further ahead in advancements in data and analytics, cost management strategies, consumer engagement, and value-based care models to drive alignment as a convener in the future.
While health plans have demonstrated value creation by deploying social programs, a truly scalable model that drives sustainable cost reduction has not been proven. Figure 3 highlights examples of point solutions that address specific social needs. Based on point-to-point solutions and market-based solutions as seen below, we believe conveners can sustainably drive 5% of medical cost savings by aligning appropriate parties to comprehensively address social determinant factors and truly improve community health. Health plans with larger Medicaid and Medicare populations can demonstrate the greatest return on investment; however, we see opportunities across lines of business for group and individual members.
Figure 3: SDOH Examples
Today, only one or two entities collaborate to address a singular need within their communities. This fragmented narrow focus serves a singular value proposition rather than provide a broad community-based care approach. To drive long-term value, the understanding of unique consumer needs and the differences across markets will require a convener to create tailored programs at the intersection of a consumer journey point and market dynamics.
Figure 4: Consumer Journey & Market Based Approach
The payer, acting as a convener, holds unique insights into market demands and member needs regarding social determinants. These insights will be critical in developing adaptable and fluid approaches to addressing SDOH factors that often vary between regions, creating unique market profiles across the country. For example, the needs of members in urban, suburban and rural markets will vary based on different demographics and social barriers.
Figure 5: Market Archetype Overview
By viewing unique member needs through the lens of local market dynamics, conveners can create targeted SDOH programs with the greatest impact. In the example below, a convener leverages its understanding of the unique member needs and local market to create a value-driven engagement model.
The role of a convener varies significantly by market, but the personalization and understanding of local dynamics remains the same. In an urban market like Providence, a convener must address an ethnically diverse population with lower levels of financial security; a convener in a rural market such as Ellsworth, Kansas, grapples with convenient and timely access to basic necessities (e.g., healthcare, fresh food, fitness facilities). Additionally, a convener in suburban markets such as Pasco County, Florida, must examine barriers stemming from long work commutes and a high crime rates. In each market, a convener must consider systemic challenges in developing SDOH solutions. For example, linguistic and cultural barriers are focal areas for a predominantly non-English speaking market like Providence, whereas social isolation is the critical focus in a rural market such as Ellsworth.
Figure 6: Urban Convener Example
Paramount to becoming a convener, health plans must develop a coherent strategy addressing investments across people, process, technology and data analytics. These investments reflect the drivers behind successful implementation of an integrated approach to SDOH that health plans are primed to lead.
Figure 7: Integrated Health Plan Convener Operating Model
Health plans will need to transcend historical approaches to member data (e.g., enrollment, claims) to adopt a more predictive and comprehensive model that addresses gaps in social and preference factors.
Humana completed a Comprehensive Social Needs Survey Channel Test for over 100,000 members which helped identify financial strain, housing insecurity, and transportation access issues. Humana reviewed data sources across social needs assessments, EHRs, encounter data, census, and CMS and made a strategic enterprise investment in data management and governance to leverage this data to better address the social needs of its population.
Health plan investment in business capabilities and processes will unite policy, clinical delivery, and community-based resources to deliver effective SDOH programs:
Accolade, a customer advocacy company serving employers, develops a personalized integrated care plan for all members. As part of this critical process, Accolade leverages social and behavioral data from its members and employer geographies to build a robust member profile. A personalized care plan is critical for member engagement as they sell to employers with a wide variety of socio-economic status employees.
Conveners require accountable roles dedicated to community and social needs as well as a specialized workforce that engages members in their health outcomes:
SCAN Health Plan, a California-based Medicare Advantage plan, utilizes well-trained care managers with customer service experience to help dually enrolled members navigate their benefits. Additionally, SCAN launched a program to integrate social workers and community health workers into the care team to help support physicians in addressing SDOH. The efforts adopted by SCAN Health Plan illustrate the intersection between members, providers, and community organizations. The health plan sits at the middle of this intersection, capable of coordinating and driving efforts through meaningful investment in human capital.
Investment in advanced data management and integration removes silos and enables advanced workflows that augment member engagement and administration of SDOH programs.
Unite Us, a care coordination, software developer, provides a digital platform to handle external referrals between community organizations and providers as well as tracking patients’ outcomes and care journey. The focus Unite Us places on connecting organizations across silos and enabling seamless coordination provides a model for conveners to follow.
The current COVID-19 pandemic amplifies the need for a convener to address social barriers for access to care and the impact of non-clinical factors on health care access, quality, and outcomes. The ability to socially distance safely, find safe and healthy food sources, and access transportation are highly influenced by social status and the consequences of inequality. As of early April 2020, African Americans made up ~50% of COVID-19 cases in Chicago and ~70% of deaths, but represent only 30% of the total population. COVID-19 is highlighting the outcomes of social disparities. The underlying causes for these disparate outcomes are driven from social and behavioral factors. As health plans and providers seek to alleviate the short and long-term challenges of COVID-19, they should begin building programs designed to remove social barriers.
Ultimately, delivering effective SDOH programs require a convener across community organizations, clinical resources, policy-makers, and health plan coverages to obtain a holistic view of an individual’s clinical and social / behavioral factors which impact health outcomes. Payers are best positioned to play the role of convener due to their broad access to key stakeholders (community organizations, clinical and policymakers), investment capital, and member touchpoints. To develop an effective SDOH strategy, we recommend building toward a convener role through the following steps:
An effective SDOH program is key to driving long-term value as a health plan. From insight to execution, HealthScape works with plans to address social determinants and barriers.
Contact Jesse Owdom for more information.