For managed-care plans focused on improving population health and reducing overall costs, the goal has to be on prevention, not just treatment. One increasingly popular strategy is targeting members based on social determinants of health (SDOH), which accounted for around $2.5 billion in spending between 2017 and 2019, according to a 2020 study. But how can plans make sure their investments in SDOH initiatives will bear fruit and make them more competitive in the market?
"In terms of enrollment, when you look at plans that are showing growth, every single one in the top 10 has very aggressive SDOH initiatives," explained Carlos Baltodano, vice president of healthcare and government solutions at Ubiquity, a BPO that operates SDOH campaigns for health plans. Although each organization tasked with building its SDOH program will have distinct objectives, one of the first steps and most critical factors in developing that strategy is collecting and understanding SDOH data.
Know the data
Many examples of how SDOH data is used to reduce costs and improve care can be seen throughout the payer community in the United States. One insurer that provided managed care primarily through Medicaid and Medicare for more than 6.3 million members, developed a data integration and evaluation approach to measure the effect of connecting members with social services to help with medical expenses and improve overall health, including closing gaps in quality care and member satisfaction. In 2019, the program demonstrated a 37% care-gap closure due to its SDOH strategy and a 9% average claims cost savings versus a similar population control group.
The strategy required gathering and analyzing data from a wide range of disparate resources, said EmmaLee Ericksen, formerly lead SDOH strategist at the company. "We'd look at SDOH data around employment, neighborhood or healthy food [access], or housing stability, for example, and in terms of connecting members to services, we'd rely on local communities, information about programs and the eligibility requirements. The SDOH data would then be linked to internal healthcare claims and quality care gap closure data to determine the cost savings. "By developing a data repository of resources by location, you can quickly connect individuals with services based on their specific needs," she added.
Closing the loop on member care
To better understand the lives and health of its members, and to help guide them to community services, the payer built an internal call center to collect information using a social-needs assessment. It then took that data and combined it with potential external social services.
"The goal was to try to connect with as many people as we could to provide information about resources and at the same time to speak to specific members that may not be reaching out for help," Ericksen said. The payer partnered with community-based organizations who would then provide further data around member usage of external services. The payer integrated their demographic and community-based data with quality-of-care data, clinical data and claims data. Their technology team then built predictive analytics or artificial intelligence (AI) algorithms that would identify open care gaps or at-risk populations by region.
"From that, we were able to identify specific members and have an idea what their predicted needs would be and combine that with all the demographic, claims and care-management information for them. Our call center could then reach out to those individuals with local services. It was really impactful to tie that all together and allowed us to close the loop on member care between clinical and social services," Ericksen added. At the same time, it allowed the payer to measure the impact of a specific intervention in terms of healthcare outcomes.
The importance of outreach
The payer's SDOH strategy couldn't have been carried out without the capacity to reach the members in the community. That's where the "field engagement team" came in—collecting needs-assessment data as well as conducting targeted outbound campaigns, and implementing specific pilot programs to solve complex health and social challenges.
Any SDOH outreach program has to put the member first, said Baltodano. "It's all about the member experience, making sure they feel comfortable discussing their personal health and having the necessary depth of information to offer them the right assistance," he noted.
SDOH program impacts run the gamut from a reduction in claims cost and inpatient stays to an improvement in quality scores, which are affected by things like a member's housing stability or preventative care usage. "However, if you want to understand the true impacts of your SDOH strategy, it starts with thinking about what success looks like for your organization and building your data around that," Ericksen concluded. "To truly create sustainable and impactful payer-driven SDOH programs, it's critical to look at the needs of the membership populations and communities you serve."
The ability of SDOH initiatives to improve the overall health of members has become a primary focus in the industry, Baltodano said. "However, as we continue into the future, it will be the realized savings from reduced medical expenses over each covered individual's lifetime that will become an insurmountable competitive advantage for SDOH early adopters."