By Arreyellen Salyards*
The COVID-19 crisis has exposed inequalities in the US health care system as people of color and low-income communities are disproportionately impacted. For example, in Milwaukee, African Americans account for three-quarters of COVID related deaths, and in New York City people living in zip codes in the bottom 25 percent of average income accounted for 36 percent of all cases, while the wealthiest 25 percent accounted for under 10 percent of cases. These disparities demonstrate the need for an investment in the underlying social, economic, and environmental factors that can have a significant impact on health outcomes. These factors are often referred to as social determinants of health (SDOH). Examples of SDOH include access to transportation, affordable and adequate housing and education, proper nutrition, and safe communities in which to work and play. Medical care alone directly influences only 20 percent of health outcomes, while providing social services to prevent more costly conditions helps positively affect the other 80 percent of health outcomes.
The insurance industry has recently started to pay attention to the social determinants of health, in part spurred on by the federal government. For example, the U.S. Department of Health and Human Services has incorporated SDOH objectives into national initiatives like Healthy People 2020. Perhaps more pertinently, the Centers for Medicare & Medicaid Services (CMS) published new rules for 2020 that allow insurers to offer supplemental, SDOH-related benefits for Medicare Advantage (MA) plans. Companies who have taken advantage of this include Aetna, Anthem, Cigna, Humana, and UnitedHealth Group. These benefits include the reimbursement of telemedicine services, expanded transportation options, fitness programs, companionship benefits, and adult day care. The agency has also successfully worked with states seeking to integrate SDOH into their contracts with Medicaid managed care organizations.
Even prior to CMS’ directive, in June 2019, America’s Health Insurance Plans (AHIP)’s Board of Directors charged the organization with recognizing SDOH as an “essential part of the industry’s long-term vision for improved health and financial security.” AHIP launched Project Link, an initiative that brings together health insurers from across the nation to establish strategies and goals to ensure new SDOH are effective and sustainable in improving health status and affordability. Accordingly, insurers have engaged in efforts to improve SDOH in order to cut costs, improve health, reduce spending, and support communities. To better understand how and where major health insurers are investing in SDOH, we reviewed announcements from eight health
insurance companies about their SDOH initiatives in 2019, including:
Insurers’ SDOH efforts are largely supported by their philanthropic arms, and do not involve changes in coverage or benefits
Our review found that insurers use their charitable grant programs to combat SDOH problems, but they are not, in general, changing benefit designs, reimbursement policies, or other business practices. For example, the Florida Blue Foundation, Blue Cross Blue Shield of Florida’s philanthropic arm, invested $9 million to support local organizations that focus on crisis management, mobile clinics, home care, and health literacy. Similarly, Molina’s Community Innovation Fund pledged $1 million annually for three years, beginning in 2019, to fund community organizations that address SDOH for Washington’s Medicaid beneficiaries. This program supported NeighborCare Health’s Youth Clinic to expand access to mental healthcare for youth experiencing homelessness. Aetna’s philanthropic initiative, Building Healthier Communities, invested $100 million over five years to expand SDOH-related services and tools in its participating states, like Ohio, where it gave $2.5 million to organizations that tackle issues like opioid abuse.
Housing initiatives dominate insurers’ investments
Several of the companies reviewed have invested heavily in improving housing. For example, UnitedHealth Group has invested $400 million since 2011 into 80 affordable housing initiatives, creating over 4,500 new homes in underserved communities. UnitedHealth’s data from its Medicaid plans show that access to stable housing leads to more effective health management for its members by decreasing the use of costly services, like ER visits. The company believes that lack of safe and affordable housing is “one of the greatest obstacles to better health[.]” Similarly, in 2019, Aetna invested more than $50 million to provide housing services to its Medicaid and Dual-Eligible Special Needs Plan (DSNP) members. Additionally, the company will provide funding to organizations that offer resources on independent living, social services and financial literacy.
Insurers are tracking their investments through data collection, results reporting, and program analysis
While there is strong evidence that social determinants influence members’ health outcomes, it can be difficult to measure the return on investment for insurers. For example, these programs differ by community, local health organizations often measure results in non-standardized ways, and enrollees may switch to other forms of coverage before any impacts can be realized. Some insurers are investing to improve evaluation of their programs through data collection and program analysis. For example, Blue Cross Blue Shield of RI has started using the RI Life Index survey to measure the social factors influencing health and wellbeing in the state to better identify challenges and resources in specific geographic areas. UnitedHealth Group has invested in creating two dozen new ICD-10 codes related to SDOH, which can trigger referrals to social supports, and aims to expand health system data reporting to include SDOH categories. In effect, the company can identify non-clinical barriers to health for their members, which serves to better match future funding efforts with actual community need. Expanding these codes also provides an opportunity for increased payments both to insurance companies and SDOH providers.
Take Away: Recently, insurers have been investing in improving SDOH, but are largely doing so through charitable donations. Few insurers appear to be changing benefit designs or reimbursement policies in their commercial products, although recent government rules are encouraging them to expand coverage of SDOH-related benefits in their Medicare Advantage and Medicaid products. Some commercial insurers are taking steps to develop metrics and tools to evaluate whether investments in SDOH can generate a return in the form of improved outcomes or lower health care expenditures. If these evaluations do show a successful return on investment, then we could see greater integration of SDOH into insurers’ coverage and reimbursement policies.
*Arreyellen Salyards is a graduate of Georgetown University’s Health Care Management and Policy program. She worked as a health policy intern at CHIR during her Spring semester, 2020.