Converging Social Determinants of Health and Medicaid Managed Care

Converging Social Determinants of Health and Medicaid Managed Care

Policymakers are recognizing the impact that social and economic factors have on a consumer’s approach to healthcare. Access to housing, healthy food, and income must be taken into consideration as a person determines the appropriate health plan coverage. Social determinants of health (SDOH) can control up to 80% of health outcomes according research by the Robert Wood Johnson Foundation (RWJF). This statistic encompasses mainly Medicaid’s low-income enrollees who struggle with covering basic needs.

In this blog we’ll discuss the growing focus around Medicaid Managed Care and how social determinants of health can recover health outcomes.

Social Supports and Health Plan Care Management

Medicaid Managed Care (MCOs) programs can operate within states by requiring MCOs to connect beneficiaries to social supports as part of their care management solutions. RWJF states “24 states now require MCOs to screen beneficiaries for unmet social needs and help them to address those needs. In North Carolina, for example, MCOs are obligated to refer people to food, housing, transportation, domestic violence resources, and to track the outcome of their referrals.” For consumers considered high-need, beneficiaries within those states require MCOs to provide in-person help.

SDOH Interventions

Considering the impact of SDOH is still surfacing, states can participate in evaluating the effectiveness of their SDOH regulations. It is vital for states to assess whether SDOH interventions work outside of high-need and high-cost populations. If a specific state utilizes a Medicaid waiver as the foundation for their SDOH, Centers for Medicare and Medicaid Services (CMS) should include these evaluations as part of the waiver. If a state relies on managed care-based strategies, they can also conduct such evaluations. RWJF points out, “Michigan, for example, requires MCOs to develop and submit a multiyear SDOH plan. As part of this plan, MCOs must articulate how they will use data to support their efforts and what SDOH-related measures they will report.”

Value-Based Payments and Social Interventions

Medicaid cannot be used to finance the cost of providing accessible housing and other social services. On the contrary, they can encourage and offer providers to make these disbursements. In more detail, RWJF explains, “Value-based payments reimburse providers for achieving specified outcomes and containing costs, rather than the volume of services that they provide.” A state could fundamentally allow a provider to give a beneficiary whatever services are necessary. For instance, Arizona requires MCOs to allow 50% of their reimbursement to providers through value-based payments. Providers can offer housing to homeless beneficiaries in lieu of paying for medical bills they would incur if they continued to live on the streets.

Medicaid agencies and Medicaid health plans increasingly recognize the value of addressing the social determinants of health impacting beneficiaries. Softheon is taking part in the conversation at the Association for Community Affiliated Plans (ACAP) 2019 CEO Summit in Washington DC on Thursday, June 20th-June 21st. To learn more about Softheon’s comprehensive solutions and cloud-based platform, visit our exhibit table to speak with Kevin Deutsch, Managing Director of Health Plans.

The views and opinions expressed by the authors on this blog website and those providing comments are theirs alone, and do not reflect the opinions of Softheon. Please direct any questions or comments to



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