MedCity Influencers

Considering social factors helps plans engage hard-to-reach medicare and medicaid members

As clinicians and plans providing care management programs understand more about the social factors of the member’s life outside of the doctor’s office, they will be able to use that information to design targeted outreach efforts and close care access gaps.


Across our country, millions of Americans lack basic needs making it hard for them to access care and prevent illness. Yet those same needs are definitively linked to poor health outcomes. For families who are economically disadvantaged, poverty creates a ripple effect that touches every aspect of their lives. Not surprisingly, factors such as where a person grows up, lives, works and ages also play a huge role in influencing health outcomes and can reset our biology, for better or worse.

Collectively, these non-medical factors such as lack of housing, lack of transportation, financial instability, and food insecurity – or “social determinants of health” (SDoH) – can account for as much as 80 percent of health outcomes. In fact, the Centers for Disease Control and Prevention (CDC) report that social determinants are the no. 1 factor in health inequality.

Given that social determinants play such a significant role in the lives of vulnerable populations, especially those who are disabled and living in poverty, health plans managing these populations through Medicaid managed care, Health Insurance Exchanges, and Dual-Eligible Demonstrations are seeking new approaches to address and solve social issues impacting members.

At first glance, this may seem out of the scope of a plan’s usual purview, however addressing social determinants is a smart business decision that can significantly decrease cost and utilization. Research has shown that unmet social needs are associated with higher rates of hospital admissions, readmissions, and emergency room use. For example, supportive housing was shown to decrease Medicaid costs by up to 67 percent in a Massachusetts pilot program, including reduced emergency room visits and inpatient admissions.

Yet meeting these needs can be complicated because the represent nonclinical issues and do not fit tidily into a typical managed care model. Instead, reducing social barriers that prevent or limit access to care requires engaging people in the communities where they live and personalizing the outreach.

Using Data to Uncover and Identify Social Issues
One of the first steps that a plan can take is to understand and identify the individuals facing barriers and what those barriers are so they can be factored into the design of an engagement plan. Sources of data that can be considered in this process include:

  • Social data (income, education, level of community support, environmental data, etc.)
  • Health care utilization (clinical history, pharmacy usage, hospitalizations, etc.)
  • Consumer behavior (demographic data, psychographic, etc.)
  • Member interaction (care management, customer service, online engagement, etc.) 

Start with human behavior
Regardless of how challenging an individual’s SDoH factors may be, another fundamental truth in health care that must be acknowledged is that making lifestyle changes is hard.

We all know that delivering patient-centered care and effectively engaging patients in their health and well-being are essential to achieving better outcomes, lower cost, and a better patient experience. But knowing the importance of patient engagement and empowerment and actually achieving it can be challenging.

This is where the science of member engagement can help plans design choice environments that reduce the need for willpower and make healthy behavior the easy, obvious choice. Humans are predictably irrational and don’t always make reasonable decisions in their own best interests.

Often, our desire to avoid unpleasant outcomes or loss outweighs the prospect of future gain which accounts for why it can be so hard to resist an immediate impulse such as the junk food at the cash register.

Though humans are irrational, they do tend to be consistent in the basic expectations they have from any relationship. That is, to be treated as unique individuals; to get reliable and consistent care that meets their needs; to be treated with compassion; and to have clear, honest and consistent communication.

Once plans have an idea of who they want to engage, they should consider what messages will be well- received and what channels the individual prefers. Many of us have friends who respond right away via text or email, but never answer an actual call, while others let digital messages pile up because they prefer to chat on the phone.

A mix of channels is especially important to address social determinants because there may be gaps in how a plan reaches a member due to those issues. For example, if a Medicaid enrollee has an unstable housing situation, she may not even receive a direct mailer; but phone, text or email may still be reliable channels.

To help plans design an engagement program that addresses social determinants, here is a summary of best practices:

  1. Improve awareness: Increase beneficiary awareness of available community services through omnichannel communications, information dissemination, and referral.
  2. Provide assistance: Provide navigation services to assist high-risk beneficiaries with accessing services.
  3. Encourage alignment: Encourage partner alignment to ensure that services are available and responsive to the needs of beneficiaries. Optimize plan performance by aligning teams for engagement programs that address SDoH.
  4. Provide time and resources: Healthcare administrators can demonstrate leadership by setting aside time for a designated team of social workers, health care providers and behavioral specialists to work together to tackle SDoH issues that impact successful health outcomes through an umbrella member engagement and/or rewards and incentives program that segments populations appropriately.
  5. Align incentives: Plans and providers must provide the right type of incentives for their members to engage in a more meaningful and holistic manner in their own health care and well-being. Extrinsic motivators, such as gift cards or program-specific items (i.e., strollers for prenatal program participation) can kickstart member engagement and overcome SDoH barriers.

How It Looks in Real Life
One real-world example of social determinants is Hennepin County Medical Center’s (HCMC) approach to building its accountable care organization specifically around safety net providers to better coordinating clinical and social factors for its 9,000+ Medicaid population. According to an article in  Health Affairs, HCMC found its ER utilization decreased by more than 9 percent replaced by preventive and primary care visits.

They achieved this by using a patient questionnaire aimed at determining the individual’s needs related to social factors which they used to categorize patients as low, medium or high risk. Care teams included a psychologist, and clinical and social services staff who helped coordinate a variety of services including safe and affordable housing, substance abuse counseling, transportation, and dental care.

This is one of many examples that illustrate how social determinants are increasingly relevant in health care—and the impact addressing those factors can have on outcomes.

Health starts in our homes, schools, workplaces, neighborhoods, and communities. Everyone knows that taking care of ourselves by eating well and staying active, not smoking, and seeing a doctor when needed are all essential to stay healthy. But for individuals who lack shelter, warm clothing or food, their basic human needs must be met first. It makes little sense to try to educate a patient about the importance of taking their medication every day if she and her child are sleeping on friends’ couches and struggling to find a safe environment.

As this practice evolves, more examples are likely to emerge on how social determinants can be met to improve patient care. As clinicians and plans providing care management programs understand more about the social factors of the member’s life outside of the doctor’s office, they will be able to use that information to design targeted outreach efforts and close care access gaps.


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