Editor’s Note: There is mounting evidence that addressing the social and economic factors that drive the majority of health outcomes, often called social drivers of health (DOH), can improve health, promote health equity and reduce costs. With this in mind, states are increasingly integrating requirements to address DOH into their Medicaid managed care contracts.1
In October 2020, Manatt Health published “In Pursuit of Whole-Person Health: A Review of Social Determinants of Health (DOH) Initiatives in Medicaid Managed Care Contracts and 1115 Waivers” that identified common, emergent and leading-edge practices of states addressing DOH. Now Manatt has updated our analysis with new insights from a review of 15 states that have undertaken significant changes to their managed care contracts since the publication of the original survey (Arizona, California, Colorado, Hawaii, Kentucky, Louisiana, Minnesota, Nevada, Ohio, Oregon, Tennessee, Virginia, Washington, West Virginia and Wisconsin). For those 15 states, we also reviewed new approved 1115 waivers.2 These states are geographically, demographically and politically diverse from each other and have different levels of emphasis on DOH in their Medicaid managed care contracts—and as such, serve as a good sample of national trends. Given that racism also has been identified as a driver of health, Manatt has added “health equity” as a new area of focus. In addition, we provide a fresh look at cutting-edge topics, including in lieu of services (ILOS), community investment requirements, and DOH-related data sharing and report requirements.
A summary of highlights from our updated report is below. To download a free infographic spotlighting key findings—including a state-by-state snapshot of contract provisions by DOH domain—click here. To register for our webinar—sharing fresh insights from our latest research and discussing new strategies and next steps—click here. For more information on accessing the full survey, with detailed state profiles and an interactive, searchable map, contact Barret Jefferds at email@example.com.
DOH Survey Highlights
This research refresh provides a barometer of sorts of the extent to which states are continuing to innovate in addressing DOH—and they are. At a high level, states are increasing the number and breadth of DOH-related requirements for managed care organizations (MCOs).
Care Management: The most common strategy for addressing DOH in MCO contracts continues to be care management, with 14 out of 15 requiring DOH screening and coordination of social needs and all 15 requiring referral to social services. Some notable trends include:
- More prescriptive requirements around screening tools
- Increasing requirements to complement screening with predictive analytics to identify high- or rising-risk members
- Requirements for MCOs to develop and keep current directories of social services
- Expectations for MCOs to engage in “closed loop referrals” with community and social services
Workforce: Workforce requirements continue to be “emerging,” with ten out of 15 states requiring DOH-specific staff (e.g., housing specialists) and DOH-specific training for staff. Importantly, states are increasing their support for integrating community health workers into care teams. Community health workers and peer navigators often share the same life experiences and circumstances as the community they serve, are able to develop trusting relationships that support continued member engagement and can extend the reach of the care team.
Data Development, Collection, Evaluation: Standardizing the reporting and exchange of data is integral to measuring the impact of DOH-related initiatives over time. Requirements related to this area of focus continue to be “emerging”—with eight out of 15 states requiring DOH-data sharing. Six states added requirements related to data sharing, reporting on DOH initiatives and using DOH indicators in predictive analytics. Another notable trend is increasing references to having MCOs promote provider use of ICD-10 Z codes to help with documentation and data sharing on DOH needs.
Quality Metrics and Strategy: Given limited validated DOH quality measurement and improvement tools, states are less prescriptive with respect to DOH-related quality initiatives. Some states require, while others provide the option for, MCOs to focus at least one of their performance improvement projects (PIPs) on DOH-related initiatives.
Financing: Still considered leading edge are DOH-related financing initiatives such as DOH-related withholds and incentive payments, risk adjustment for social factors, use of in lieu of and value-added services, and value-based payment models to incent DOH interventions. Fewer than five states of the 15 reviewed engage in any one of these activities. Of note is the emergence of innovative strategies related to ILOS. ILOS are optional services that may be provided “in lieu of” a service or setting covered in a state plan because they are cost-effective and medically necessary.
Community Initiatives: Manatt’s research surfaced a proliferation of community investment requirements. In October 2020, only two states in the nation (Arizona and Oregon) were requiring MCOs to reinvest a portion of their Medicaid profits into the community served, and one state encouraged it (North Carolina). Since then, at least four other states (California, Hawaii, Nevada and Tennessee) have added community investment provisions in their MCO contracts.
Domains of Focus: Housing continues to be the most common DOH domain addressed explicitly in MCO contracts. In the prior version of the survey, 34 of the 37 states profiled had included housing-related provisions in contracts with health plans. In the survey refresh, all 15 states reviewed have included contract requirements related to housing.
Health Equity: Medicaid’s role in providing health coverage to a diverse group of individuals that are often among the most economically and socially marginalized has led states to integrate strategies to promote health equity3 in their MCO contracts. All 15 states reviewed in this refresh included health equity-related requirements in their MCO contracts. Requirements (from most common to least) include:
- Providing health equity training for staff, including implicit bias training
- Reporting on health disparities among membership
- Hiring of dedicated staff such as a chief health equity officer
- Creating a detailed plan on reducing disparities
- Incenting the closure of disparity gaps across member populations
Anticipated DOH Developments
DOH Interventions in MCO Contracts Will Move Further Upstream. The causes of poor health can occur at several different levels—often described as “midstream” and “upstream” causes. Midstream causes are thought of as intermediary determinants, or material circumstances affecting an individual’s health, such as housing conditions and food security. Structural causes, affecting a community or population, such as structural racism, prevalence of lead in low-income housing, limited access to healthy food or violence in the community, are more upstream. During the pandemic, the United States has seen a significant rise in upstream causes of poor health—especially poverty. To date, the majority of DOH-related initiatives in Medicaid managed care have focused on midstream causes—such as connecting homeless members to needed housing supports. We are starting to see states addressing some upstream issues through their managed care contracts.
Promoting Health Equity Will Continue to Be Front and Center in Managed Care Contracts. States are embedding significant requirements for MCOs to document and address health disparities across their membership, with an emphasis on racial and ethnic disparities. These requirements are likely to intensify and become more prescriptive over time. States are likely to continue strengthening these contract provisions by incorporating disparities reporting requirements, integrating health equity into value-based payment arrangements and holding MCOs accountable for failing to meet specified targets related to equity.
DOH-Related Contract Provisions Will Become Increasingly Prescriptive. We can expect to see additional prescriptiveness in contracting requirements being driven by state efforts to align more closely disparate players around common approaches and goals, expedite operational scale, and effectively track progress against goals.
MCOs Will Invest in New Capabilities to Address DOH Needs of Members. Integrating health-related services into the care continuum and providing access to services beyond traditional Medicaid benefits require new capabilities of MCOs. In some cases, MCOs might be required to invest in new capabilities in-house, such as technology infrastructure, staffing and training/technical assistance.
CBOs Will Play a Big Role in Bridging the Gap Between Health Care and Social Services. Community-based organizations (CBOs)—as trusted community resources—play a unique role in helping people navigate and access social services and providing community-based social services in a culturally competent manner. CBOs may be tapped to partner or contract with MCOs to help meet new DOH requirements. CBO partnerships will be essential for MCOs to meet the evolving state expectations to address members’ DOH needs.
NOTE: Manatt’s updated DOH survey is available on its own or through Manatt on Health, Manatt’s premium information service. Manatt on Health provides in-depth insights and analyses focused on the legal, policy and market developments that matter to you, keeping you ahead of the trends shaping our evolving health ecosystem. Available by subscription, Manatt on Health delivers a personalized, user-friendly experience that gives you easy access to Manatt Health’s industry-leading thought leadership. To learn more or schedule a demo, contact Barret Jefferds at firstname.lastname@example.org.
1 In prior publications, we referred to these as “social determinants of health.” We now refer to them as “drivers of health,” to reframe the conversation in a person-centered way that acknowledges the impact social factors have on health and well-being without implying that poor health outcomes are a foregone conclusion.
2 Manatt identified 22 states whose Medicaid contracts had expired between the publication of the original report and January 1, 2022. Of those, 15 states had significant updates to contract language. Manatt updated the profiles for these states. For those 15 states, we also reviewed new approved 1115 waivers. Waivers that were under development, or submitted but not approved, were not included.
3 Health equity is defined by the Centers for Medicare & Medicaid Services as “The attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes.”