Eva Powell, M.S.W., is senior manager of quality programs at the Alliance of Community Health Plans, an organization representing nonprofit health plans ranging from large, multistate ones to smaller regional plans. Many have turned to the alliance for guidance on how to respond to the CHRONIC Care Act, which offers plans greater flexibility in designing supplemental benefits for Medicare Advantage members and, for the first time, the option to tailor these benefits to discrete populations. Transforming Care asked Powell what she’s heard from plans so far.
Transforming Care: What’s been the response of your members to the CHRONIC Care Act?
Powell: The plans are very excited and recognize the flexibility as something that’s been needed. There’s a lot of work required to take advantage of these flexibilities, though. Health plans have to make a lot of decisions about who qualifies for new benefits, how that benefit will be delivered to their members, and how they will sustain that financially. And many of these new benefits don’t fit neatly into traditional health plan processes. For example, how do you represent fresh food on an Explanation of Benefits form? It takes some time to work through these issues.
Transforming Care: To what extent are plans now aware of members’ social needs?
Powell: Almost all are doing some sort of social needs assessment, though it varies as to which tool they use and which populations they survey. As a general rule, you have to have a plan in place to respond to any needs identified, so this isn’t as simple as just conducting a survey. The ideal is to have a standard way to identify and update social needs for all patients. But the benefit of doing so is in sharing that information with other care team members and making referrals to resources outside the health care system, and there isn’t a standard, effective way of doing that yet. And in many communities the social resources needed simply aren’t available. So, you can see how health plans both believe they have an important role to play in addressing social needs but are also asking a lot of questions about the specifics of that role.
Transforming Care: Where do you expect them to focus?
Powell: Food and transportation are more concrete, and therefore easier places to start, than some other determinants of health like poverty and housing. But several of our member plans are addressing housing needs, as well. We are seeing plans starting to become more strategic by evaluating the social needs that have the most significant impact on their members and communities and then working to find ways to address them. Many plans are starting to realize that partnership with community-based organizations is critical — and what that looks like is far more complex than donating a lump sum of money to something that benefits the community in some general way. Partnership means coming to an agreement on shared goals related to addressing social needs, which is no easy task.
Powell: Yes, and some plans are building their own. Health plans and providers recognize that one role they can play in addressing social need is assessment and referral. That’s where digital platforms come in. They also help with sharing information with care team members and community agencies.
Transforming Care: How do health plan leaders think about financing the services they do want to purchase from community-based organizations?
Powell: I think it varies depending on what they are trying to do and what the expectation for return on investment is. For some initiatives, like medically tailored meals, there is a business case to be made. These could be built into a health plan’s benefits. In other cases, philanthropy needs to be tapped to support social needs. Another option is social innovation funding, which matches organizations that need capital with mission-oriented investors looking for both financial and social ROI. The investors are reimbursed if the intervention yields savings. We also need to think about eliminating low-value care and repurposing dollars that are being wasted on care that is either harmful or unnecessary so it can be put toward things that prevent the need for care. I think we also need to look at how public funds are spent and how other systems, like education and law enforcement, can play a role. Ultimately, social need is a societal problem, not a health care problem.
Transforming Care: Do you think plans are concerned about adverse selection; that is, attracting sicker patients by offering richer benefits?
Powell: We aren’t really hearing that. What our plans are indicating is that the barriers they are facing are related mostly to a limited availability of supplemental funding and uncertainty around financial impact of making these investments. Many, if not most, of our plans are very focused on reducing premiums, so that is more of a priority than adding social benefits. Reduction of premiums — while not a social benefit — could very well have a positive impact on economic stability, one of the root causes of social need.
Transforming Care: Given the challenges you’ve outlined, what’s a realistic timetable for the rollout of new benefits?
Powell: I think we will see more uptake in 2020 than in 2019, and it will continue to grow as people learn what works and develop innovative ways to finance initiatives. As the Better Care Playbook demonstrated, there is a clear ROI for food programs. Housing may be harder to execute due to the investment required, even though there’s a clear, concrete need.
Transforming Care: What else might plans need from the Centers for Medicare and Medicaid Services (CMS) in terms of guidance?
Powell: Plans would benefit from CMS guidance that specifies any constraints on innovation so that they have the freedom to try new ideas without running the risk of falling out of compliance with regulatory requirements.