- Medicare Advantage beneficiaries are increasingly likely to be affected by socioeconomic and demographic factors contributing to worse health outcomes, stressing the importance of plans providing non-medical benefits targeted for these high-cost, high-need patients, according to a new Avalere analysis. The finding was especially strong for MA members eligible for both Medicare and Medicaid.
- The healthcare consulting firm analyzed claims and ZIP code data from more than 1.8 million MA beneficiaries for the 2015 plan year. It found more than half of the dual eligible population lived in a neighborhood with a median income below $30,000 and more than half lived in a neighborhood where at least 20% of households earned below the federal poverty level. That's compared to roughly 16% and 19% for their non-dual counterparts.
- Avalere also found dual eligible beneficiaries in MA were less educated on average, another social determinant of health factor linked to worse outcomes. About 64% of duals lived in a neighborhood where fewer than 20% of the population had a bachelor's degree or higher, compared to 37% of non-duals.
Along with having less wealth and a lower level of education, dual eligible MA beneficiaries are on average more likely to be young, female, disabled, of a racial or ethnic minority and from an urban area than the non-dual MA population.
These social determinants of health (SDOH) contribute heavily to poorer health, Avalere found, heaping more evidence onto the impact outside factors have on medical outcomes. Multiple studies have shown a person's ZIP code is more important for health outcomes than their genetic code — ZIP code being a traditional stand-in for a host of SDOH factors like education, exercise, diet, socioeconomic status and more.
Dual eligible beneficiaries performed worse on the majority of quality outcomes in Avalere's analysis, including using 70% more high-risk medications and 18% higher rates of avoidable hospitalizations. They were more likely to suffer from chronic conditions including depression (2.3 times more likely), Alzheimer's (2.4 times) and diabetes, asthma, heart failure and stroke (all between 1.5 and 2 times more likely).
"There's no debate any longer that social determinants are as important to your health as the healthcare you get," Avalere researcher Christie Teigland told Healthcare Dive. "Where it's not so reflected is in payment."
About 35% of Medicare beneficiaries have opted into the privately-run MA plans, which proponents champion as lowering costs while providing a wider swath of services. That figure is only expected to grow as plans expand their service offerings and payers, spurred by mounting enrollment and growing CMS reimbursement, increase their focus on MA.
Payers like CMS are beginning to incorporate SDOH benefits into their plans.
"They're developing a menu of choices of nonmedical benefits and, at the top of that list, I do see transportation, I do see food, I do see housing," Teigland said, although she said most payers weren't doing enough.
In early April, CMS finalized a rule giving MA plans regulatory flexibility to provide benefits attempting to address SDOH, such as buying fresh produce for beneficiaries with cardiovascular conditions or carpet cleaning for those with asthma. Such benefits are easier to provide in value-based insurance such as MA or Medicaid managed care programs, where payers are directly responsible for keeping the overall cost of care low.
Although CMS Administrator Seema Verma argued it would be too costly to offer comparable benefits in fee-for-service programs, some big players are trying to inject SDOH into those areas. Earlier this year, UnitedHealthcare and the American Medical Association joined for an initiative to create 23 ICD-10 billing codes clinicians could use to "prescribe" community services and resources to tackle housing, food and financial insecurity.