There are almost 33 million people enrolled in eligible Medicare programs. Nearly half are enrolled in Medicare Advantage (MA) plans, and that number is expected to continue its climb. While many MA plans offer services that align with social determinants of health (SDOH) goals, there are still gaps in how these services reach and support vulnerable populations. This challenge is multifaceted. Critical issues include:
- An incomplete understanding of how MA services impact different SDOHs for at-risk populations and contribute to beneficiary outcomes
- How to best integrate social risk into the value-based care model is unclear, leading to a misalignment between payments and goals
- Insufficient training for clinicians on social risk within care settings, available programs for Medicare patients, and how to connect patients with impactful support
Organizations often struggle to use data effectively due to poor data integrity and insufficient analytics. When a new member joins, MA plans usually lack insights into beneficiaries’ claim history, morbidity risk, and health behaviors. Without that data, understanding social risk becomes difficult for identifying beneficiary needs, guiding interventions, and ultimately improving health outcomes. Building trust through tailored services can help MA plans retain beneficiaries in the long term.
Strategies for MA Plans to Address Social Needs
1. Providing Accessible Information to Beneficiaries
MA payers should focus on making information about their services accessible and inclusive. This means delivering information that is:
- Straightforward and easy-to-find
- Written at an 8th-grade reading level or lower
- Translated into multiple languages
- Optimized for consumers with disabilities or neurodivergence
- Inclusive in language and imagery
This approach ensures that more people, especially those facing barriers like language or cognitive limitations, can understand the services available to them and make informed choices about their care.
2. Enhancing Provider Education on SDOH Programs
Nurses, doctors, and pharmacists are among the most trusted professionals in the U.S., so they are often the primary source of information for patients. MA plans must ensure providers are well-informed about available services, as this increases the likelihood of patients benefiting from these programs. This can be accomplished by:
- Developing workshops and training sessions on SDOH and available MA services.
- Creating provider-facing resources that simplify the process of referring patients to social support services.
- Establishing direct lines of communication between MA plans and providers to keep them updated on service changes and enhancements.
3. Building Community Partnerships for Targeted Interventions
MA plans can gain insight and improve community engagement by partnering with local organizations, particularly in areas with high percentages of BIPOC or LGBTQA+ residents. Collaboration with community health workers and support organizations allows MA plans to:
- Tailor interventions that are culturally sensitive and relevant to the unique needs of each community.
- Enhance program reach by leveraging trusted, local resources to connect with beneficiaries who may not engage directly with MA plans.
- Improve outreach effectiveness through culturally informed messaging that resonates with community values and experiences.
4. Integrating Behavioral Health with SDOH Efforts
Behavioral health is closely linked to social risk factors. Addressing mental and behavioral health as part of SDOH efforts can help MA plans provide a more comprehensive care experience. For instance, partnerships with mental health providers and integrating behavioral health assessments into routine care can support beneficiaries more holistically, potentially reducing hospitalization rates and improving quality of life.
Regulatory Changes and Cost Savings from Addressing SDOH
Recent regulatory changes reflect an increased focus on SDOH within Medicare Advantage. These regulations require MA plans to take on more responsibility in collecting and reporting SDOH-related data. Key areas of focus include:
- Mandatory SDOH Data Collection:
- MA plans are now expected to collect data on social risk factors more systematically. This includes information on income, housing stability, access to healthy food, and other non-clinical factors that influence health. This shift means that plans need robust data systems to integrate social risk information alongside clinical data, enabling more precise population health management.
- Reporting Utilization of Supplemental Benefits:
- Another significant regulatory change requires MA plans to report the utilization of supplemental benefits, such as transportation services, nutrition programs, and other SDOH-related services, directly to the Centers for Medicare & Medicaid Services (CMS). This transparency enables CMS to assess the impact of these additional services on beneficiary health outcomes and evaluate the return on investment for such services.
- To comply, MA plans should establish efficient tracking and reporting mechanisms, ensuring they accurately capture the usage of these services. This also allows MA plans to refine their offerings based on service utilization data and beneficiary feedback, driving better alignment with community needs.
- Impact of SDOH Interventions on Cost Savings:
- Addressing SDOH not only improves health outcomes but also significantly reduces healthcare costs. A recent study by Adobe Population Health reported that targeted interventions addressing social needs like food, housing, and transportation led to an average annual healthcare cost reduction of nearly 30 percent per member. This reduction demonstrates the financial impact that SDOH interventions can have on healthcare systems.
These regulatory changes and evidence of cost savings make it clear that SDOH interventions are critical to value-based care strategies for MA plans. By focusing on social risk data, MA plans can provide better-targeted services, improve outcomes, and lower costs—benefiting both beneficiaries and the healthcare system as a whole.
Expanding Technology and Data Integration to Address Social Risk
To succeed in addressing SDOH, MA plans need robust data infrastructure that integrates clinical, claims, and community data. This integration enables a more holistic understanding of each beneficiary’s social risks, guiding targeted interventions. For example:
- Using interoperable data systems that connect clinical data with community resources ensures beneficiaries receive the most relevant support.
- Building privacy-respecting data-sharing frameworks to ensure compliance with HIPAA and other regulations can increase beneficiary trust in MA plans.
MA plans should also consider partnering with data analytics firms to enhance their capacity to analyze and act on SDOH data. With the right tools, they can make more informed, cost-effective decisions about which benefits to offer, how to incentivize providers, and how to engage beneficiaries at the community level.
Measuring Success and Adapting Over Time
Key performance indicators such as reduced hospitalization rates, improved chronic disease management, and increased patient satisfaction can help MA plans gauge the success of their SDOH initiatives. Regularly reviewing these metrics allows for timely adjustments to strategy, making it possible to refine and improve interventions over time.
Ultimately, MA plans that effectively address social determinants will meet compliance standards and improve the quality of life for millions, achieving their mission of better health for all. By bridging the gaps in data, education, and community engagement, Medicare Advantage programs have the opportunity to lead the healthcare industry in addressing social risk and advancing equitable health outcomes.
About Brian Norris, MBA, RN, RHIMSS
Brian Norris, MBA, RN, FHIMSS has more than 25 years of experience in healthcare, 20 of those years as an RN and 15+ years in analytics, value-based care, and product development. As Vice President & Managing Director of Strategic Consulting, Brian leads the MedeAnalytics consulting practice focused on helping clients advance their value-based care strategies, deliver phenomenal outcomes to their populations, and assist organizations across the healthcare vertical with their most pressing clinical, operational, and outcomes challenges.
