Social determinants of health could have more influence on a person's outcome than the actual care received. Addressing those factors is increasingly important for insurers.
Real progress on addressing social determinants of health (SDOH) to improve outcomes and quality of care within a health plan population could depend on gathering SDOH data and making it accessible to the frontline provider.
For years, health plans have been talking about SDOH—socioeconomic and societal issues that can affect people's health and impede proper healthcare delivery—but finding a way to apply it and gain some practical benefit for both the insurer and the customer has been challenging, says Gabriel Medley, vice president of quality and risk adjustment programs at Gateway Health.
Gateway Health provides Medicaid services to about 500,000 people in Pennsylvania, Delaware, and West Virginia, and Medicare coverage in Pennsylvania, Kentucky, Ohio, and North Carolina.
SDOH data will become increasingly important to health plans as they develop ways to collect better information on SDOH and put it to use, Medley says.
Gateway Health is making headway using data to gain better insight into their population’s socioeconomic barriers to care. The approach can support members who might have otherwise fallen through the cracks if SDOH were not captured, Medley says.
"The future is a data game. The health plans that are able to keep up with the member with dynamic, current, useful information in a cost-effective, real-time way are the ones that will be at the forefront of improving quality for the member," Medley says.
"We have to nest that SDOH data with claims experience and all other different buckets of data flowing to create a common picture in a risk stratification model, then place that information wherever that member is getting care," he says.
Doctors Want SDOH
Providers are looking for SDOH data because they are tired of hearing that they are not meeting quality measures, Medley says. They realize that there are SDOH factors that affect their efforts to provide quality care, so they want to incorporate that information, he says. Such factors can account for more variance in health.
"There is a lot of information available to providers in the chart, but not all of it is provided in a way that makes it actionable in a timely fashion, and some SDOH issues are not reflected in a typical patient's medical record," he says.
"That's where the healthcare sector is going: How do you get this data in a fast, cost-effective manner, and how do you get the data aggregated and organized in a way that the provider, care manager, pharmacist, or even the call center can use it?"
Gateway Health uses a health engagement management system called HMS Eliza for SDOH data collection, as well as cost and quality management, revenue control, and customer engagement.
Gateway Health’s focus on SDOH has improved chronic disease management performance so much that it now outperforms most Medicaid plans in the country, Medley says.
There have been dramatic improvements in control measures for diabetic issues, including blood pressure and medication adherence, Medley says, as well as 40% higher engagement rates in some chronic disease measures.
Chronic disease performance metrics have improved by 3% or 4% each year for several years now, he says, with some measures reaching the 75th percentile. Clinical spending also has become more efficient, with the health plan's medical loss ratio reaching 85%.
Duals More Affected
Gateway Health is a dual eligible special needs plan (D-SNP), and Medley says that puts an emphasis on SDOH for the company. Duals are affected by SDOH more than the average consumer, he explains.
"SDOH factors are particularly important for the D-SNP population because they don't necessarily react to a care program the same way a typical MAPD does," Medley says.
"We use the SDOH data to help gauge the member's propensity to engage, how the member will react to the intervention. That helps us determine the best way to work with that member, knowing up front what the SDOH challenges might be and tailoring our intervention for the best outcome in light of that information," he says.
Many health plans are employing more outreach strategies such as texting and mailing flyers to remind patients of follow-up visits, but the effectiveness of those strategies is limited without better use of SDOH, Medley says.
"Communication is good but you can't get members to close the gaps if they have a social determinant of health that is not being addressed in their daily activities of life. The member may need shelter, may live in a food desert, or not have money to pay for food at the end of the month," he says.
He continues, "If you're trying to get a member to control one of the chronic conditions prevalent in these populations, like diabetes or heart disease, you have to remove those barriers to care for that member before you can expect them to follow through with the care you're trying to provide."
SDOH data can indicate that some members will never be able to comply with a care plan without community intervention, Medley says.
"The higher-level data collection means that you don't stop when you find out the number they gave you is no longer valid, or they don't live any longer at the address you have for them. You may be able to determine that they don't live there now and instead they're living under a bridge somewhere or at a shelter," Medley says. "We have to use that data to triangulate the intervention method that will help this person, and that may mean getting community resources involved."
Gregory A. Freeman is a contributing writer for HealthLeaders.