themes: evidence-based health care, addressing social determinants of health (SDOH) to decrease societal health care costs, addressing SDOH to improve individual health outcomes, public health, health policy
Medicare Advantage programs (not to be confused with regular Medicare) are allowed to be innovative. In fact, you may have noticed several programs are leading the way on innovation and coverage of integrative health services and other wellness-promoting and function-promoting services.
Some of this innovation is in response to recent federal health policy initiatives to address social determinants of health (SDOH) in patients and patient populations with chronic health conditions.
According to the paper, “The passage of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act in 2018 allows Medicare Advantage (MA) plans, which enroll more than one-third of Medicare beneficiaries, greater flexibility to address membersʼ social determinants of health (SDOH) through supplemental benefits.”
“To provide more benefits to address SDOH, MA plans may learn from the experience of other payment models in expanding their service offerings. While, to our knowledge, there is no evidence to date of how MA plans can better address SDOH, flexibility has existed to address SDOH and other patient needs in patient-centered medical homes, 36 accountable care organizations (ACOs),10,37-41 and Medicaid Managed Care. 42-44" [emphasis added]
Challenges these companies have when they are innovating new patient care coverage plans that address social determinants of health
- finding strong evidence base for types of clinical care or procedures that show improved patient outcomes
- finding evidence base for cost-effectiveness
- finding partners who can provide these evidence-based services
- getting clear guidance from CMS about what is permitted
"In particular, ACOs may face many of the same challenges as MA plans as they begin to take on more capitated risk, i.e., the need for a strong evidence base that addressing SDOH may improve patient outcomes and reduce costs, the ability to find partners who can provide these services, and clear guidance from CMS about what is permitted.39"
"In a 2014 qualitative study (38) of ACO perspectives on SDOH, ACOs, similar to MA plans, were interested in expanding these types of benefits but did not always know how." [emphasis added]
"The Hennepin model, (41) in which a Medicaid Managed Care agency partners with a hospital, a community health center, and the county department of health to better coordinate services, is often seen as a successful example of how organizations can address SDOH through community partnerships."Citation: JAMA Netw Open.2019;2(7): e196923. doi:10.1001/jamanetworkopen.2019.6923
"The past successes of Medicaid Managed Care in addressing SDOH may be an even more relevant example to MA plans on how an insurer can best address these concerns.(10)” [emphasis added]
More information about Medicare Advantage Programs (updates added 9.30.2019)
- How New Medicare Advantage Programs are Lowering Healthcare Costs, an article by AthenaInsight published 6.11.2019
- CMS Announcement, published 4.2019
- Community Aging in Place--Advancing Better Living for Elders (CAPABLE), a related John Hopkins program
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