Social Determinants of Health

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.

Medicaid beneficiaries of different races and ethnic backgrounds may not have equal access to non-emergency medical transportation (NEMT), suggests a new study from the Medical Transportation Access Coalition (MTAC). While only a small number of Medicaid beneficiaries use NEMT, it is more common among beneficiaries with complex, costly medical needs. When breaking down NEMT utilization by race and ethnicity, MTAC (staffed by Faegre Drinker Consulting, in partnership with the National Opinion Research Center) found that the number of riders was not proportionate to overall enrollment distribution, which “indicates that NEMT is not serving beneficiaries of different races and ethnicities equally and may suggest a need for focused education about NEMT to certain groups.” Researchers and policymakers should focus on finding and addressing the root causes of these differences, the authors asserted. American Indian and Alaska Native beneficiaries had the highest utilization rates, followed by Black enrollees, then white enrollees.

Medicaid managed care organizations this year will have their hands full as they support state efforts to resume eligibility redeterminations and try to help members avoid gaps in coverage, or “churn” historically associated with failing to meet cumbersome paperwork requirements. At the same time, MCOs may have more opportunities to address health-related social needs (HRSNs) as CMS encourages states to pursue new funding flexibilities around items like food and housing, industry experts tell AIS Health, a division of MMIT.

As a condition of receiving enhanced federal matching funds during the COVID-19 public health emergency —which will end on May 11 — states had to maintain continuous coverage for Medicaid enrollees. But the Consolidated Appropriations Act of 2023 (CAA) decoupled that requirement from the expiration of the PHE. Per the CAA, the temporary 6.2 percentage-point increase in the Federal Medical Assistance Percentage will phase down over three quarters starting on April 1, when states may begin terminating Medicaid coverage for individuals who no longer qualify. States have up to 12 months to begin — and 14 months to complete — eligibility redeterminations for all individuals enrolled in Medicaid.

A new report from the CMS Innovation Center identified redesigning financial benchmarks and risk adjustment to improve model test effectiveness as a priority going forward. In its annual report to Congress, the Innovation Center noted that “[m]any financial benchmarks and risk adjustment methodologies have created opportunities for potential gaming and upcoding among participants — and have therefore reduced savings for Medicare.” The Innovation Center largely tests models serving fee-for-service Medicare beneficiaries and has relied on risk adjustment as a critical component of its models, including all accountable care organization (ACO) based models. The agency added that it has launched “an examination of its benchmarking and risk adjustment approaches to provide incentives to encourage participation, especially among providers caring for underserved beneficiaries and ACOs with varying levels of experience, as well as ensure payment accuracy.” The report also highlighted health equity as an ongoing focus and observed ways to improve communications with potential hospice benefit enrollees, referring to one component of the ongoing Medicare Advantage Value-Based Insurance Design model, to ensure that hospice and palliative care are accessible to all beneficiaries.

SCAN Group, the parent company of not-for-profit Medicare Advantage insurer SCAN Health Plan, on Dec. 14 said it will combine with another not-for-profit organization, CareOregon. For more than 25 years, CareOregon has provided health services and community benefit programs to Medicaid and the Children’s Health Insurance Program in its home state and currently serves more than 500,000 Oregonians, including individuals who are dually eligible for Medicare and Medicaid.

Under the name HealthRight Group, the combined companies will operate as a mission-driven not-for-profit health care organization and maintain their respective consumer-facing brands, according to a press release from the firms.

As health insurers rapidly expand their technology divisions and ally with tech companies to create population health and business insights, many health care leaders have expressed a hope that new technologies and insights can help tackle social determinants of health (SDOH). Those tools hold great promise, according to experts, but must be paired with old-school, community-based coalition building to be successful.

During a panel convened for a Dec. 6 Milliman Inc. webinar, health tech experts from organizations including Independence Blue Cross and Microsoft Corp. agreed that population health and equity insights can’t move the needle on SDOH if they aren’t paired with grassroots coalitions.

The opioid epidemic — which by one measure peaked in 2017, when the Centers for Disease Control and Prevention (CDC) recorded 17,029 U.S. deaths involving prescription opioids — is far from over. In fact, CDC data show that deaths tied to prescription opioids, after declining in 2018 and 2019, came roaring back with the onset of the COVID-19 pandemic, and totaled 16,416 in 2020.

As the country continues to grapple with this stubborn issue, health insurers have learned they have a role to play in helping stop would-be opioid use disorder cases where many originate: with well-meaning doctors poised to write out a prescription. One such insurer is Pittsburgh-based Highmark, which is engaged in a multiyear partnership with a company called Wayspring to track providers’ prescribing habits and reach out to educate those who appear to deviate from the CDC’s recently updated clinical practice guidelines for prescribing opioids for pain.