Social Determinants of Health

Challenges with finding transportation is keeping many U.S. adults from accessing necessary health services, according to a recent report from the Urban Institute. Health policy experts tell AIS Health, a division of MMIT, that providing non-emergency medical transportation (NEMT) can benefit payers by enabling people to make their routine appointments and adhere to medications, which lowers the risk of high-cost hospitalizations.

However, they say that while Medicaid requires NEMT and Medicare Advantage plans are increasingly offering the benefit, NEMT remains uncommon in the commercial, employer-sponsored insurance sector.

Even when NEMT is available, its usage remains low. For instance, a study released earlier this year from the Medical Transportation Access Coalition (MTAC) found that only 4.6% of Medicaid and Children’s Health Insurance Program beneficiaries used NEMT in 2019. The MTAC, which was formed by three leading NEMT brokers and is managed by Faegre Drinker Consulting, analyzed data from 66 million people enrolled in 32 states and Washington, D.C.

More than 1 in 5 adults without access to a vehicle or public transportation missed or skipped a health care visit in the previous year, according to a recent Urban Institute study.

Using June 2022 data from the Urban Institute’s Health Reform Monitoring Survey, the researchers found that overall, about 5% of non-elderly adults reported forgoing medical care due to transportation barriers in the previous year. The experience was more common among Black and Hispanic/Latinx adults, individuals from low-income families, people with disabilities and those using public insurance.

Racial disparities in health care have become a top policy priority since the start of the COIVID-19 pandemic, which disproportionately killed people of color, particularly Black and Native American people. The Biden administration made closing racial health gaps a key part of its pandemic response — and health insurance-related policy changes going forward. One new report from the CMS Center for Medicare & Medicaid Innovation (CMMI, or the Innovation Center) says that the administration has made “meaningful progress” in closing racial disparities, and a review of health insurer equity efforts from the New York United Hospital Fund (UHF) says that “many…carriers have made substantial commitments to the communities they do business in,” but both conclude that insurers and policymakers must do far more to eliminate racial health gaps.

From CMS’s expanded definition of primarily health-related supplemental benefits to the introduction of Special Supplemental Benefits for the Chronically Ill (SSBCI), Medicare Advantage plans have gained increasing flexibility over the last few years to offer supplemental benefits that can address social needs. Through the ongoing MA Value-Based Insurance Design (VBID) model — the only MA-focused demonstration being tested by the CMS Innovation Center — MA organizations have even more flexibility to target and tailor a variety of interventions. During a recent virtual panel of the Fourth National Medicare Advantage Summit, several longtime participants of the model agreed that such flexibility is critical to meeting beneficiaries’ evolving health-related and other social needs.

CMS first tested the model on a limited basis in 2017, allowing sponsors to offer reduced cost sharing for medications and offer high-value services to beneficiaries with select chronic conditions. Today, the model allows MAOs to tailor their MA plan offerings using several approaches and has 52 MAOs offering services to an estimated 6 million enrollees.

A spate of deals and new initiatives from Kaiser Permanente, CareSource and Blue Cross Blue Shield of Michigan highlight the race for nonprofit insurers to expand and diversify in increasingly competitive markets, as well as the rise of value-based care.

Perhaps the most significant deal is Kaiser’s planned acquisition of Geisinger Health, a nonprofit health system of 10 hospitals in Pennsylvania that also operates the ninth-largest insurer in the state. If the deal gains regulatory approval, Geisinger will be the first member of Kaiser’s new Risant Health, a nonprofit alliance of health systems focused on value-based care. “Risant Health’s vision is to improve the health of millions of people by increasing access to value-based care and coverage and raising the bar for value-based approaches that prioritize patient quality outcomes,” Kaiser said in an April 26 press release. Kaiser aims to add “like-minded” regional or community-based health systems to Risant, which will operate “separately and distinctly” from Kaiser as a whole.

The Biden administration will make Medicaid coverage available to incarcerated people for the first time through a new category of Section 1115 waivers, building on a demonstration program that has been active in California since January. Experts tell AIS Health, a division of MMIT, that the waiver poses notable challenges to Medicaid managed care organizations, which will have to coordinate with the carceral system and community providers to meet the needs of a disproportionately vulnerable and sick population.

States that apply for the waiver, dubbed the Reentry Section 1115 Demonstration Opportunity, will provide Medicaid coverage to incarcerated people who are on the verge of returning to the community. According to an HHS press release, states will be allowed “to cover a package of pre-release services for up to 90 days prior to the individual’s expected release date that could not otherwise be covered by Medicaid.” The package of services includes providing formerly incarcerated people with a 30-day supply of medication on release, case management, and medication-assisted treatment (such as prescribing methadone) for substance use disorder (SUD).

Point32Health, the nonprofit health care company that was formed two years ago through the merger of Harvard Pilgrim Health Care and Tufts Health Plan, earlier this year launched a partnership with Included Health to better serve LBGTQ+ health plan members and their families.

Starting on Jan. 1, Tufts Health Plan’s fully insured commercial beneficiaries began gaining free access to Included Health’s LBGTQ+ Health product through which they can connect with care coordinators who can answer questions and refer them to services such as in-network gender-affirming care providers. Harvard Pilgrim’s fully insured commercial members will gain access to the product later this year.

CareSource and Walmart Inc. have struck a new deal that will see Walmart aim to improve care for pregnant Medicaid enrollees and CareSource members who require treatment for cardiometabolic conditions in Ohio, building on a partnership announced earlier this year to deliver pregnancy care to CareSource members in Georgia. The deal could be a model for similar partnerships between Medicaid managed care organizations and retailers, experts say, and demonstrates Walmart’s interest in achieving national health care scale.

CareSource, a nonprofit insurer covering 2.3 million lives (2 million of which are in Medicaid plans) in five states, will partner with Walmart to “address racial health inequities” by connecting eligible CareSource members with Walmart’s “in-store community health workers.” Eligible members “will receive monthly funds to spend on food, a Walmart+ membership for no cost, and access to tele-nutrition services to aid in improving their health outcomes,” according to a press release. The move comes just weeks after Walmart and CareSource agreed to a similar arrangement focused strictly on prenatal, early maternal and children’s health care in Georgia, a partnership that also includes Johnson & Johnson. Neither CareSource nor Walmart responded to requests for comment by press time.

With the maternal mortality rate in the U.S. notoriously higher than many other developed countries and care access issues a perennial concern, payers can play an important role in efforts to improve perinatal care. During a recent session at AHIP’s Medicare, Medicaid, Duals & Commercial Markets Forum in Washington, D.C., panelists discussed how a deeper understanding of coverage data can fuel those efforts.

Medicaid pays for more than four in 10 births nationally and more than half of births in some states, said Usha Ranji, associated director for women’s health policy at the Kaiser Family Foundation (KFF). Federal law requires all states to provide Medicaid coverage for pregnancy-related services to women with incomes up to 133% of the federal poverty level and cover them up to 60 days postpartum, but many states have extended the income threshold “well over 200%” of FPL, according to Ranji.

A new study published in the Journal of Clinical Oncology found that cancer afflicting adolescents and young adults cost the health care system $23.5 billion in 2021, and $259,324 for the average patient over a lifetime. The findings come as the American Cancer Society reported that incidence of colorectal cancer is becoming more common among that cohort: 20% of new colorectal cancer diagnoses in 2019 were for patients younger than 55, compared with 11% in 1995, per the Wall Street Journal. Experts say that to help, insurers can educate patients and improve access to screenings and care coordination.

Fortunately, the overwhelming majority of adolescents and young adults who are diagnosed with cancer have a positive prognosis: in 2019, the 5-year survival rate for people in that cohort was 85% “with prompt diagnosis and timely delivery of appropriate therapy,” per the Journal of Clinical Oncology study. Approximately 90,000 people ages 15-39 in the U.S. are diagnosed with cancer annually — that’s about 5% of all new cancer cases. The increasing incidence of colorectal cancers contrasts with falling adolescent and young adult death rates “each year between 2010 and 2019,” the study said. Experts say systemic issues make detecting and treating cancers in the adolescent and young adult cohort difficult.