Social Determinants of Health

In August, Highmark Inc. launched a new Medicaid managed care organization in West Virginia, becoming the Mountain State’s first Blue Cross Blue Shield-branded MCO. In doing so, the insurer will confront challenges that MCOs of all stripes are facing, such as building a comprehensive provider network and grappling with the financial pressures related to states resuming their routine eligibility checks after a multiyear pause.

The West Virginia Dept. of Human Services approved Highmark Health Options’ application to be the state’s newest MCO in January, giving the not-for-profit organization a statewide contract that runs for four years. Highmark Health Options will compete against a trio of MCOs in West Virginia that include Elevance Health, Inc.’s Unicare Health Plan of West Virginia, Aetna Better Health of West Virginia, and The Health Plan’s Mountain Health Trust. As of September, Highmark Health Options West Virginia had attained roughly 1,800 members, according to AIS’s Directory of Health Plans (DHP).

Aging in place, lack of transportation and economic insecurity are the top social threats to seniors’ health, according to new data from Alignment Health. Sponsored by the tech-enabled Medicare Advantage insurer, the third-annual Social Threats to Aging Well in America survey polled more than 2,000 seniors across the U.S., asking them about their financial, physical and emotional needs — and how those needs are impacting their health. Their responses also highlight the types of supplemental benefits that could prove most valuable to seniors as they consider their coverage options while the 2025 Annual Election Period looms.

Senior-focused primary care organizations can enhance access to care for Medicare Advantage members, particularly among historically underserved groups, according to a new study of Humana plans that was conducted by the insurer’s research arm. The research, which was published in Health Affairs and co-authored with Harvard researcher J. Michael McWilliams, M.D., Ph.D., highlights the potential of population-based payment models to drive equity in health care delivery. Additionally, this research comes as Humana and other large insurers plan strategic exits from the MA market after experiencing sustained medical cost pressure in public sector insurance.

While plenty of telehealth and online drug dispensing companies have rolled out direct-to-consumer (DTC) offerings, two pharma manufacturers have unveiled their own digital platforms this year in a bid to streamline and simplify consumers’ experience with the U.S. health care system. Other drugmakers are likely to launch similar offerings, say industry experts, as they offer benefits to various stakeholders. Still, certain challenges exist for those stakeholders, and manufacturers will need to ensure that they take certain steps — both pre- and post-launch — to set themselves up for success while remaining compliant with various regulations.

On Aug. 27, Pfizer Inc. launched PfizerForAll, a “user-friendly digital platform designed to make access to healthcare and managing health and wellness more seamless for people across the U.S.” It is aimed at Americans with migraine, COVID-19 or flu and offers adult vaccinations for conditions such as COVID-19, flu, respiratory syncytial virus (RSV) and pneumococcal pneumonia.

L.A. Care Health Plan and Health Net announced on Aug. 28 they have launched two programs that will collectively invest $90 million over five years to help people experiencing homelessness receive access to care. The health plans will invest $60 million in the L.A. County Field Medicine Program, in which 19 providers will provide coordinated care. They also will invest $30 million in the Skid Row Care Collaborative, which will include harm reduction services, extended hours for urgent care and pharmacies, and onsite specialty medical services in Los Angeles’s Skid Row neighborhood. The programs could assist about 85,000 Los Angeles residents, according to L.A. Care and Health Net, which is a division of Centene Corp.

A federal district judge on Aug. 26 ruled in favor of TennCare beneficiaries who alleged the state’s Medicaid program caused thousands of residents to lose coverage after the introduction in 2019 of an electronic eligibility determination system, Fierce Healthcare reported on Aug. 28. “After years of litigation, plaintiffs have proven TennCare violated their rights under the Medicaid Act, the Due Process Clause of the Fourteenth Amendment, and the Americans with Disabilities Act,” the judge wrote. Fierce noted the state may appeal the court’s ruling. The Tennessee Justice Center, National Health Law Program and National Center for Law and Economic filed the lawsuit in March 2020.

The long-term care needs of the nation’s “silver tsunami” of 65-and-older population — a wave that began as the first of the baby boomer generation turned retirement age in 2011 — continue to elicit challenges in the broad health care buckets of spending, coverage, access to services and disparities in care. But during a recent webinar, experts discussed some promising solutions, including one health insurer’s initiative that takes a caregiver-centric approach to post-acute care.

Such pervasive problems in long-term care, an industry with a $415 billion tab in annual spending, were the primary theme of an Aug. 7 National Institute for Health Care Management (NIHCM) webinar, an event that framed the contributory elements of the country’s “long-term care crisis” — namely, underinvestment, a lagging workforce, fragmented care and an industry that often fails to take a person-centered approach.

One year in, most of the initial active participants in CMS’s Enhancing Oncology Model (EOM), a value-based, patient-centered care model, are still involved in the program. Participants tell AIS Health, a division of MMIT, that overall, the experience is going well, but some concerns exist around issues including social determinants of health (SDOH) and whether the reimbursement is appropriate for what CMS is requiring.

The purpose of the EOM is “to drive transformation in oncology care by preserving or enhancing the quality of care furnished to beneficiaries undergoing treatment for cancer while reducing program spending under Medicare fee-for-service.” CMS says it “envision[s]” that the model not only will improve quality but also lower costs “because its payment methodology is aligned with care quality, and because EOM participants will have significant opportunities to redesign care and improve the quality of care furnished to beneficiaries receiving care for certain cancers.” The model makes physician practices accountable for total costs of care.

CVS Health Corp. announced on Aug. 1 an initiative to provide timely excessive heat alerts and outreach to at-risk members of Aetna health plans. CVS is focusing on people “most vulnerable to extreme weather events that can worsen existing chronic conditions,” according to a press release. This fall, it will expand to people who are susceptible to reduced lung function, asthma and cardiac problems. CVS plans to make the service available eventually to its MinuteClinic and CVS Pharmacy locations. CVS said care managers have worked with “hundreds of at-risk patients” in 20 states since launching the initiative two weeks ago.

Ever since racial justice activism swept the country in 2020 following the death of George Floyd, racial disparities in health care have become a focus in the health care industry. Perhaps even more than in recent years, health equity was one of the most-discussed topics at the AHIP 2024 conference in Las Vegas.

But presenters at the conference made clear — as have their counterparts at other industry meetups — that health equity is a work in progress. Awareness of racial health disparities may be at an all-time high, but tangible progress is as elusive as ever.

The use of supplemental benefits in Medicare Advantage can markedly improve health care utilization, decreasing members’ inpatient admissions and increasing wellness visits and preventive screenings, suggests new research from Elevance Health, Inc.’s Public Policy Institute. And the effect is especially pronounced for Medicare-Medicaid dual eligibles, who are more likely to have greater care needs and face socioeconomic vulnerabilities.

Following legislation and regulatory changes in 2018 and 2019 that established new types of supplemental benefits and expanded the definition of what CMS considers “primarily health-related,” payers began to offer supplemental benefits that target these health-related social needs, such as food insecurity and lack of access to transportation.