Prepare for the Future of Health Equity

Amidst new healthcare regulations and market challenges, social determinants of health stand as one of the most important, but challenging, areas of interests for quality programs and regulators. Government agencies have enacted significant regulatory policies to expand equitable care to all members and continue to increase expectations from health plans.

From the Star Ratings program to Medicaid Managed Care Organization contracts, regulators have implemented new and creative ways of incentivizing health plans to deliver equitable care. The more financial performance becomes tied to health equity initiatives, the more important it is for health plans to account for social determinants of health to safeguard revenue.

To prepare for the future of health equity, health plans need to understand where regulations currently are, where they are headed and how plans can adapt to the upcoming changes.

What are the Social Determinants of Health?

Social determinants of health (SDOH) represent underlying, non-medical factors that influence members’ physical and mental health. A mixture of socioeconomic and systemic issues, these elements exist outside of a member’s control and are difficult for them to overcome on their own. SDOH limit their ability to access care, self-manage medical conditions and improve their quality of life.

SDOH include:

• Environment
• Living conditions
• Income level
• Disabilities
• Race
• Ethnicity
• Sex
• Gender identity
• Sexual orientation
• Education

Research suggests that clinical care only determines 20% of health outcomes, while SDOH account for 50% of outcomes. For members to reach their full healthcare potential, physical and mental conditions must be addressed alongside SDOH.

Why Does SDOH Matter to Health Plans?

At a plan-level, SDOH contribute to higher healthcare costs, lower quality scores and ineffective care programs. This occurs because SDOH create barriers to care that prevent members from receiving appropriate care without additional assistance from plans, government programs and community resources. Since these issues are systemic, they affect large populations and create significant health disparities.

Health disparities can manifest as wide gaps in care and poorer health statuses for members who experience SDOH compared to unaffected members. For example, members with limited English proficiency often struggle to schedule appointments and use benefits. Failing to identify member preferred languages and communicate within them prevents health plans from engaging members in their care, closing care gaps and reducing cost of care.

To improve the overall health of members and plan performance, plans need to develop equitable initiatives that consider a member’s health status and provide appropriate SDOH interventions.

How do Government Policies Impact SDOH?

Under the direction of the United States Health and Human Services (HHS), federal and state regulators have developed various policies to guide health equity initiatives.

One of the most notable and impactful is the Patient Protection and Affordable Care Act (ACA). Through the Healthcare Marketplace®, the ACA closed long-standing disparities in coverage for vulnerable and low-income individuals. The HHS estimated that over 58 million women and 37 million children gained access to preventive care through private insurance following the passing of the ACA. In addition, Medicaid and Children’s Health Insurance Programs provided coverage for over 55 million individuals of racial and ethnic backgrounds in 2020.

Alongside expansions in coverage, agencies have directed health plans to reduce disparities for vulnerable populations through quality improvement programs. Health agencies have approached this in different ways within the Medicaid, ACA and Medicare Advantage.

For example, roughly three quarters of Medicaid states require Managed Care Organization contracts to conduct screenings for social needs, refer members to social services or work with community organizations to directly address SDOH. In contrast, California’s ACA program, also known as Covered California, launched the Quality Transformation Initiative to direct health plans to improve health outcomes for vulnerable populations across several quality measures.

New regulations within the Star Ratings program have challenged Medicare Advantage plans to take direct action against health disparities. Starting with the 2025 Star Ratings, CMS will incentivize Medicare Advantage plans to close care gaps for members with limited income subsidy, dual eligibility with Medicaid and disabilities. Plans that increase quality scores for these demographics above minimum national benchmarks will receive additional points on their overall Star Ratings.

What is the Future of Health Equity?

The future of health equity will continue to be shaped by guidance from HHS and adjustments to quality improvement programs. To effectively respond to these regulatory changes, health plans need to consider two major frameworks:

• Healthy People 2023 provides a national framework for addressing public health issues according to five main goals, three of which directly relate to health equity, SDOH and health literacy. This framework prioritizes 359 core objectives related to these goals to guide health plans, government agencies and community leaders towards meaningful health equity targets. Health People 2030 also shares research and resources with health plans to help organizations develop evidence-based health equity initiatives.
• CMS' Framework for Health Equity for 2022-2032 outlines the department's priorities regarding health equity and SDOH. The framework focuses specifically on government-sponsored health plans, including Medicare Advantage, Medicaid, Children’s Health Insurance Programs and ACA plans. As new regulations are developed to address health equity in these markets, the framework will have an influential role on how they are implemented.

As seen with the Health Equity Index, CMS has already begun modifying the Star Ratings program to reduce disparities based on these priorities, and plans in all markets should prepare for the impact on quality programs.

For example, the Agency for Healthcare Research and Quality is mobilizing health plans to address SDOH through the Social Need Screening and Intervention (SNS) measure. Announced in 2022, the SNS measure directs health plans to screen members for unmet needs regarding food, transportation and housing and provided a related intervention within 30 days of the screening. This new measure will drive health plans to develop more comprehensive health risk assessments to account for SDOH and member engagement initiatives to address social needs.

Another element to consider is the increased regulatory focus on value-based care. A value-based care (VBC) payment model pays providers based on the health outcomes achieved by their services and has the potential to more effectively incentivize providers to address SDOH in treatment plans. CMS is testing this model with Accountable Care Organizations in several markets and intends to shift Medicare Advantage plans completely to VBC by 2030. Research has demonstrated that this model improve health plan revenue by reducing readmissions and overall costs of care.

These changes to quality measures are only the start of more sweeping health equity initiatives that health plans need to understand and adapt to with comprehensive strategies.

How to Prepare for the Future of SDOH

A lot of groundwork needs to be laid to properly address SDOH at a plan level. Point solutions will have little effect on these systemic issues, and plans need to foster wide-spread diversity, equity and inclusion (DEI) initiatives across their organizations to succeed in the new landscape.

To start, plans should focus on:

• Data management: Most health plans lack insight into which members contend with SDOH, which interventions are effective and what services members need. Integrating SDOH into member profiles provides a more comprehensive view of patient experiences and enables plans to develop personalized solutions. This data should come from enrollment documentation, customer service interactions, health information exchanges and self-attested surveys.
• Stakeholder participation and recruitment: Recruiting and partnering with the right stakeholders ensures that initiatives are guided by experienced teams who understand on-the-ground health equity challenges. DEI should be incorporated into recruitment efforts, training programs and leadership development to ensure that health equity and quality teams reflect the populations they serve.
• Whole-person care: This is a model for improving health outcomes by considering the physical, mental and socioeconomic factors that impact a member’s care. Through the lens of whole-person care, health plans can incorporate SDOH into care plans to provide members with the right treatment, tools and resources to manage their health.
• Community partnerships: Community organizations are faced with the public’s SDOH on a daily basis and likely already know where resources should be directed to make improvements. Establishing strong partnerships with community leaders enables plans to implement targeted solutions to populations that need it most.
• Value-based care: The adoption of VBC by regulators presents health plans with new opportunities to address SDOH and reduce disparities through increased provider engagement. Plans should work closely with provider networks to develop VBC contracts that benefit both parties while accounting for health equity initiatives.
• Omnichannel outreach: To effectively engage hard-to-reach and vulnerable populations in their care, plans will need to use different communication models. Plans should evaluate their current member engagement capabilities and establish the right technology partnerships to support omnichannel outreach. Closing data gaps in member contact information and communication preferences is also key to improving engagement.

The road to equitable care requires powerful technology solutions, regulatory insights and meaningful partnerships. Through the combination of Healthmine’s Expert Advisory Services team and suite of digital tools, health plans have access to the right resources for addressing SDOH and improving population health outcomes. If you need assistance building health equity initiatives or understanding current and upcoming regulatory challenges, reach out to us for assistance.