For many people, the term healthcare conjures up mental images of doctors and hospitals trying to successfully treat patients after they have already fallen ill or become injured. While historically this has often been the case, as more of the industry moves towards a managed care model, healthcare is slowly becoming less about treating the ill and more about keeping people healthy.
Managed Care Organizations (MCO) come in a number of forms, they may be physician’s associations, hospital networks, or even private healthcare companies. But they all share the common trait of having moved away from fee-for-service payment models in order to find new strategies that improve patient outcomes while simultaneously controlling costs. This goal is particularly critical when looking at vulnerable populations such as those who suffer from homelessness, chronic illness, or negative impacts of the Social Determinants of Health (SDoH). These individuals have a high probability of being heavy utilizers of healthcare resources while still achieving poor long-term outcomes.
The majority of these high-risk individuals rely on Medicaid for their access to healthcare and so state Medicaid programs, and the MCOs they contract with, are particularly focused on finding ways to help these patients live healthier lives. One of the most critical, and successful, strategies for achieving this goal is to screen for and then address the social determinants that negatively impact individuals’ health. Recognizing the importance of this strategy, nineteen state Medicaid programs require their contracted MCOs to screen for the SDoH and then refer patients to the resources needed to address any identified risks. While not required, an additional sixteen states encourage this practice.
Though there are dozens of programs across the country that use the managed care model to address the Social Determinants of Health, we wanted to highlight just three.
Connected Communities for Health
In 2017, the Upper Peninsula Health Plan (UPHP), which is an MCO based in Marquette, Michigan, was awarded a Pinnacle Award in the Community Outreach Collaborative category in recognition for their program known as Connected Communities for Health (CC4H).
CC4H launched in 2016 and is designed to improve the outcomes of members and control costs by identifying and addressing social needs such as adult education, childcare, employment, utility assistance, and necessities such as food and housing. This program works in conjunction with the existing UPHP support system. When a member calls into the support line with any type of question regarding their coverage, they are screened for any concerns relating to the social determinants of health. If a concern is identified, the regular support team will transfer the member to the CC4H team, which is staffed by paid interns, where they are referred to community partners for any necessary services. After a referral is given, the CC4H team follows up with the individual within 10 days to verify that the resources met the member’s specific needs.
Comprehensive Community Health Program (CCHP)
Maricopa County, Arizona is home to Mercy Care’s Comprehensive Community Health Program (CCHP). CCHP is specifically designed to address the needs of individuals who experience mental health challenges or substance use disorders and are unlikely to recover without underlying social factors being addressed. The program functions as a collaboration between the City of Phoenix, several mental health resources, and the local United Way. This diverse group of partners gives CCHP access to the resources necessary to address a wide variety of individual needs.
Mercy Care members may be identified as potential participants in CCHP if they have frequent inpatient treatment, regular interaction with emergency responders, or insufficient housing. Housing is actually a particular focus of this program, with the City of Phoenix providing 275 housing vouchers to be distributed among qualified clients. Once enrolled, the various partners utilize a “no wrong door” approach so that individuals can be assessed and then referred to needed resources by any participating organization.
Though there are still challenges to overcome, such as the length of time it takes to find individuals affordable housing, the CCHP has seen notable success. During the previous fiscal year, members participating in the CCHP program saw a 28 percent reduction in hospitalizations and a 33 percent reduction in crisis services usage.
North Carolina Department of Health and Human Services
While many MCOs across the country are developing unique programs to address the SDoH, North Carolina is in the process of implementing a statewide initiative. In October 2018, the state received approval for a Section 1115 Demonstration Waiver to transition their Medicaid program from fee-for-service to managed care. As part of this transition, which is slated to be completed by the end of 2019, the state has developed a standardized screening program that is designed to identify risks in areas such as nutritious food, housing/utilities, transportation, and interpersonal safety. Any MCO contracting with the state Medicaid program will be required to adopt this standardized screening program and then help members access any community resources necessary to address identified needs.
Coordination and Data Sharing
The managed care model allows for the payment flexibility to take healthcare outside of the clinic and bring in a variety of community resources to address diverse needs. But programs like these are only possible when all of the participating health and human services providers have the ability to securely track and share data, manage referrals, and build comprehensive health records for their clients. Without the technology to fuel collaboration, MCOs would be unable to improve outcomes and control costs through truly whole-person care.