Author: LBodnarchuk

Social determinants of health (SDOH) are conditions in the environment that affect individuals’ wellbeing, quality of life and health outcomes. They are commonly grouped into domains that include economic stability, education access, healthcare access, living environment and social support. It is important to screen for these determinants in clinical settings because research shows that social determinants of health are linked to negative health outcomes. Standardizing screening tools and providing appropriate community-based resources to patients will help decrease negative health outcomes (Sokol, 2020).

The Institute of Medicine (IOM) recommends that screening tools include common domains such as educational attainment, financial status, social isolation and median income levels as social stability domains (National Academies of Sciences, Engineering, and Medicine, 2016). A review of the literature found that 70% of screening tools measure at least 8 out of the 15 recommended domains and that only 66% of the tools that were reviewed were commonly used in clinical practices (Meon et al., 2020). Although payers and providers recognize social determinants of health as a problem, organizations still struggle to implement and accurately report SDOH data. How can implementation be improved? What makes screening programs successful?

Screening Tools and Barriers to Implementation

There are a wide range of screening tools being used in clinical settings to identify at-risk members. Common screening tools such as Health Leads and PRAPARE are used to assess and address patients’ social determinants of health.

Health Leads screens an individual for adverse social determinants across 13 social needs domains (Health Leads, 2019). The questionnaire is evidence-based and is used in clinical settings. PRAPARE is also a nationally standardized tool used to assess patients’ risks and experiences (PRAPARE, 2022). The standardization of both tools allows them to be easily used by practitioners and integrated into EHR platforms. Despite having standardized tools, without a standardized approach, providers struggle to accurately capture, report and provide appropriate community-based resources for their most vulnerable patients (Fitzhugh et al., 2021; Meon et al., 2020). Standardization is a challenge because tools screen across different domains and lack a common approach to measure duration of time that patients experience social determinants of health. Although these challenges exist, providers have found success by utilizing evidence-based screening tools and developing a community-based approach to provide patients with needed resources (Bleacher et al., 2019).

Health Plans Combatting Social Determinants of Health

University of Pennsylvania Medical Center (UPMC) implemented “Cultivating Health for Success”, a program that partners with community organizations to provide permanent housing to members (Sokol, 2020). The program saw a savings of $6,384 for each of their participating members. UPMC was able to identify their at-risk population and provide them with a permanent solution to better control their social environment and health outcomes. Since the initiation of this program, several other programs at UPMC have been implemented to combat social determinants of health.

The success of the initiatives at UPMC was driven by practitioners recognizing that social determinants of health are interconnected and the importance of screening and identifying at-risk members. By providing members with the necessary community-based resources, UPMC saw significant cost savings because members were better able to manage their health. UPMC also recognized that data collection is paramount to understanding the “full picture” of a member to drive change.

How ProspHire Can Help

The first step to addressing health disparities in your community and across patient or member populations is to understand the underlying drivers of health in your population. That understanding will allow you to execute targeted programming that positively impacts your patients and their health outcomes, driving cost savings related to these disparities. At ProspHire, we have the experience and skillset to help you take that first step. We can partner with your teams to help you implement strategies that drive health equity forward. Connect with us today to learn more.

Resources:

Bleacher, H., Lyon, C., Mims, L., Cebuhar, K., & Begum, A. (2019). The feasibility of screening for social determinants of health: seven lessons learned. Family Practice Management, 26(5), 13-19.

Health Leads Screening Toolkit. Health Leads. (2019). Retrieved April 20, 2022, from https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/

Fitzhugh, C. D., Pearsall, M. S., Tully, K. P., & Stuebe, A. M. (2021). Social Determinants of Health in Maternity Care: A Quality Improvement Project for Food Insecurity Screening and Health Care Provider Referral. Health Equity, 5(1), 606-611.

Meon, M., Storr, C., German, D., Friedmann, E., & Johantgen, M. (2020). A review of tools to screen for social determinants of health in the United States: A practice brief. Population health management, 23(6), 422-429.

Sokol, E. (2020, January 29). How UPMC coordinates compounding social determinants of health. HealthPayerIntelligence. https://healthpayerintelligence.com/news/how-upmc-coordinates-compounding-social-determinants-of-health

Healthcare organizations today are under pressure to deliver quality care while managing costs. Benefits optimization in healthcare is one strategy that can help achieve these goals. By evaluating and optimizing product benefits, organizations can provide their members with favorable core and supplemental benefits based on market trends while also managing costs.

One of the key drivers of increased enrollment for healthcare organizations is the benefits optimization cycle. The application of benefits optimization in healthcare can lead to significant increases in enrollment, improvements in operational efficiency and financial improvements over time.

In this blog post, we’ll explore the concept of benefits optimization in healthcare, including its definition, examples of its applications and the timeline for its implementation. Understanding the benefits optimization cycle can help you make informed decisions about your product benefits.

What Is Benefits Optimization in Healthcare?

Benefits optimization refers to the process of maximizing the value of plan benefits an organization offers to their members. It aims to strike the balance between offering competitive benefits while keeping costs manageable.

Through data analysis, healthcare companies can identify areas where they can reduce costs while still providing valuable benefits by examining an organization’s enrollment and benefit utilization data. For example, an organization can identify trends based on what plans are receiving greater enrollment or which benefits are the most utilized by plan. Additionally, healthcare consulting firms can help organizations assess and optimize their product benefits to ensure they align with their short and long-term business goals.

Overall, benefits optimization in healthcare is all about finding the right balance between member need, member satisfaction, and cost control. By leveraging data analysis and expert guidance from healthcare consulting firms, organizations can ensure they’re providing competitive benefits while keeping costs manageable.

Examples of Benefits Optimization Applications

Benefits optimization is a vital aspect of healthcare management that can help organizations maximize the value of their product benefits while reducing costs. Here are a few examples of how healthcare providers can apply benefits optimization:

1. Cost Analysis and Benchmarking

Organizations can use cost analysis and benchmarking techniques to identify areas of high healthcare spending and compare their product benefits to industry standards. This helps them understand where their healthcare dollars are being spent and identify opportunities to reduce costs while still providing high-quality benefits to members.

2. Plan Design and Strategy

Benefits optimization also applies to plan design and strategy. By analyzing healthcare data and member utilization patterns, organizations can tailor their benefits programs to meet the specific needs of their enrollees. This can include offering more flexible benefits options, such as telemedicine or wellness programs, to encourage healthier lifestyles and reduce healthcare costs.

3. Vendor Management

Optimizing vendor management is another way to reduce healthcare costs while still providing high-quality benefits. By negotiating better contracts with vendors, organizations can save money on healthcare expenses and offer more comprehensive benefits to their members.

4. Compliance and Reporting

Compliance and reporting are critical components of benefits optimization in healthcare. Organizations must comply with state and federal regulations and report accurate data to regulatory agencies. Benefits optimization consultants can help organizations navigate these requirements and ensure they comply with all applicable regulations.

Overall, benefits optimization can provide significant benefits to healthcare organizations. By analyzing data, tailoring benefits programs to member needs and negotiating better vendor contracts, organizations can save money while still offering high-quality benefits to their members.

What is the Benefits Optimization Cycle?

The healthcare benefits optimization cycle is a systematic approach to improving healthcare benefits programs, encompassing various stages from assessment to measurement. By following this cycle, healthcare organizations can effectively analyze, strategize and optimize their benefits offerings.

Let’s explore each stage of the benefits optimization cycle and understand how it aligns with the Centers for Medicare and Medicaid Services (CMS) deadlines.

Assessment

The first step in the cycle is conducting a comprehensive assessment of current and emerging market benefits. This involves analyzing data on healthcare costs, member utilization patterns and satisfaction levels. Leveraging publically available data, one can quickly and efficiently have a strong grasp of the current marketplace. By understanding the existing program’s strengths and weaknesses, organizations can identify areas for improvement.

Strategic Planning

Based on the assessment, organizations develop a strategic plan to design new plan benefits or modify existing ones. This includes setting clear goals, defining strategies to achieve those goals and outlining the necessary steps for implementation.

Also, organizations might develop new products, expand their provider network or implement new healthcare technologies. Strategic planning also involves considering CMS deadlines, such as the Initial Enrollment Period, Annual Enrollment Period, Open Enrollment Period and Special Enrollment Period.

Implementation

In the implementation stage, healthcare organizations roll out their new or modified benefits programs to members. This step may include communicating with members to explain changes to their benefits packages, training healthcare providers on new processes or technologies or implementing new member engagement programs. Timely execution is crucial to meet CMS deadlines and ensure a seamless transition for members.

Measurement

The final stage of the benefits optimization cycle is measuring the outcomes and effectiveness of the implemented strategies. Organizations track key metrics such as cost savings, member satisfaction and healthcare utilization to assess the success of the optimized benefits program. This data-driven evaluation enables continuous improvement and helps organizations refine their strategies for future optimization cycles.

By following this cycle, healthcare organizations can optimize their benefits programs to increase enrollment, operational efficiency and financial performance.

The Benefits Optimization Cycle Timeline

The benefits optimization cycle timeline can vary depending on the healthcare organization and the specific benefits program the organization is optimizing. However, most benefits optimization cycles follow some general timelines: 

• Assessment: The assessment stage of the cycle typically takes place at the beginning of the year and typically takes one to two months to complete.

• Strategic planning: The design stage typically follows the assessment stage and may take anywhere from two to four months to complete. 

• Implementation: The implementation stage typically takes place in the latter half of the year and generally takes one to three months to complete. 

• Measurement: The measurement stage typically takes place at the end of the year and can take one to two months to complete. 

Here’s an example of the CMS application and bid submission timeline to understand how it aligns with the benefits optimization cycle:

• November to February (Q4 to Q1): During this period, organizations submit a notice of intent to apply and complete the CMS application by mid-February.

• March (Q1): The bid kickoff takes place, initiating the bidding process.

• End of March (Q1): The first draft of benefits is completed, outlining the proposed benefits, coverage options, and associated costs.

• April (Q2): Value-Based Insurance Design applications and the second draft of benefits are due.

• Before May (Q2): The third draft of benefits is finalized.

• May (Q2): The final proposed benefit review and assumptions finalization takes place.

• June (Q2): The bid submission deadline arrives, and organizations submit their finalized bid packages to the CMS.

By aligning the benefits optimization cycle with the CMS application and bid submission timeline, healthcare organizations can ensure a comprehensive and compliant approach to optimizing their benefits programs in order to achieve strategic institutional goals.

Remember, the specific timeline may vary based on organizational needs, CMS requirements and other factors. However, following a structured timeline is key to achieving successful benefit optimizations in healthcare. 

Maximize Your Healthcare Benefits With ProspHire

Benefits optimization in healthcare can help organizations maximize their benefits, reduce costs and increase member satisfaction. By following the benefits optimization cycle, organizations can continuously evaluate their product benefits, identify opportunities for improvement and implement changes to achieve their desired outcomes.

ProspHire offers expert benefits optimization services to help organizations navigate the complexities of healthcare benefits and achieve their goals. If you’re interested in learning more about how ProspHire can help your organization optimize its benefits, fill out our contact form today.

Over the last decade, there has been increasing research and awareness surrounding the impact of Social Determinants of Health (SDOH) on health. The Centers for Disease Control (CDC) reports that SDOH have a greater impact on health than genetics or access to healthcare services.¹ Organizations from the international level to the local level are prioritizing interventions that advance health equity by producing policies and increasing funding for programs and interventions with an SDOH focus. The World Health Organization (WHO) defines SDOH as “non-medical factors that influence health outcomes”² and the US Department of Health and Human Services (HHS) has grouped SDOH into 5 domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment and Social and Community Context.³ The Centers for Medicare and Medicaid Services (CMS) is also showing their commitment to SDOH through their updates to the Medicaid and Medicare programs.

Medicare Advantage Plans’ Opportunity to Support SDOH

Prior to 2019, Medicare Advantage (MA) supplemental benefits had to be primarily health-related and offered on a uniform basis to all plan enrollees; but in 2019 CMS updated these guidelines to allow MA plans to cover benefits tailored to certain populations that address social needs or long-term care needs. MA plans can now offer benefits to enrollees who have a specific health status (Special Supplemental Benefits for the Chronically Ill or SSBCI) and offer benefits that directly address SDOH.⁴ Some of these benefits cover food insecurity, home safety, transportation and non-opioid pain management. Since these guidelines were updated, there has been a continued increase in organizations offering these benefits. According to research by ATI Advisory, in 2022 the number of plans offering SSBCI increased by almost 40%.⁵

As shown in Figure 1, the most common SSBCI benefits offered in 2022 were categorized as food and produce, pest control, transportation for non-medical needs, meals, social needs benefit and general supports for living.⁵ Figure 2 reports the number of plans that offered these SSBCI supplemental benefits to their members in 2022.

Health plans serving the Medicare population are critical to driving health equity. In 2022, there were more than 28 million people enrolled in a MA plan and over half of these enrollees had at least one unmet SDOH need (AARP).⁷ By designing their supplementary benefits, these organizations prioritize what services are valued and have the opportunity to greatly impact members’ health outcomes and even their own Return on Investment (ROI). Offering benefits that impact SDOH can reduce the total cost of care, improve utilization, increase member satisfaction and result in higher member retention. In a study conducted by WellCare Health Plans and the University of South Florida College of Health, they found that people who were successfully connected to social services had a 10% reduction in healthcare costs.⁸

SDOH is innately complex and a study by NORC at the University of Chicago points out that there are further complexities in addressing SDOH. The study suggests that providers don’t have difficulties understanding what benefits each plan offers, who is eligible and what is necessary for their patients to sign-up.⁹ The article even suggests that providers feel they need to become experts in supplemental benefits to fully support their patients.⁹ Similarly, beneficiaries have limited awareness of what they have access to. Care Managers become increasingly important in identifying eligibility and enrolling in services. Therefore, organizations that choose to offer these supplementary benefits need to understand how to effectively manage them to fully see the benefits for their members and their ROI.

The Challenges to Implementing SDOH Supplemental Benefits

Like many of the governing agencies throughout the United States, SDOH is at the forefront of many payer organizations’ goals for the coming years. Even America’s Health Insurance Plan (AHIP) launched “Project Link” which aims to bring together payer organizations across the United States to build sustainable SDOH solutions.¹⁰ In 2019, their board said that SDOH is an “essential part of the industry’s long-term vision for improved health and financial security.”¹⁰ There has been an increase in supplemental benefit offerings impacting SDOH each year since 2019.¹¹ Thoughtful and deliberate implementation of the benefits is critical to success for the payer organization, the provider and the members themselves. Benefit design and selecting which benefits to offer is often the first hurdle for payer organizations. The ability to understand the SDOH impacting the organization’s members allows the organization to use these benefits as a differentiator from competing plans – these benefits can entice members and increase enrollment. The benefits can also serve members in a way that improves their health outcomes and eventually decreases medical costs and increases the ROI.⁸ After the supplemental benefits are chosen, it’s also important to roll them out in a way that providers, care managers and members can understand. Availability, eligibility, the process to use the benefits and the potential benefit of the benefits need to be well-communicated.

How ProspHire Can Help

At ProspHire, we understand the importance of SDOH and strive to promote health equity. We also understand the complexities and barriers that healthcare organizations face when trying to do the same for their customers. Our team of practitioners have extensive healthcare industry knowledge and are ready to discuss your SDOH goals and how we can help you reach them. Connect with us today.

References

1. Why Is Addressing Social Determinants of Health Important for CDC and Public Health? |<<n About | CDC
2. Social determinants of health (who.int)
3. Social Determinants of Health – Healthy People 2030 | health.gov
4. CMS finalizes Medicare Advantage and Part D payment and policy updates to maximize competition and coverage | CMS
5. Advancing Non-Medical Supplemental Benefits in Medicare Advantage | Resources for Innovations in Care | ATI Advisory – Chartbook: 2022 New, Non-Medical Supplemental Benefits
6. DEPARTMENT OF HEALTH & HUMAN SERVICES (cms.gov)
7. SDOH-among-older-adults-2017_IssueBrief_COR-Final.pdf (aarp.org)AARP – SDOH-among-older-adults-2017_IssueBrief_COR-Final.pdf (aarp.org)
8. Social determinants shown to reduce healthcare spending | Healthcare Finance News
9. Innovative-Approaches-to-Addressing-SDOH-for-MA-Beneficiaries-FINAL.pdf (bettermedicarealliance.org)
10. AHIP – Insurance Companies Are Investing in the Social Determinants of Health, But Widespread Changes in Benefits Remain to be Seen – Center on Health Insurance Reforms (chirblog.org)
11. MA-Supplemental-Benefits-Milliman-Brief_20220225.pdf (bettermedicarealliance.org).

May is Mental Health Awareness Month – a reminder to all of us that checking in on your mental health is just as important as your physical health. Nationwide mental health trends reveal an increasing concern. The Substance Abuse and Mental Health Services Administration (SAMHSA) notes that one in five adults in the United States have a mental health or substance abuse disorder¹. Nationwide trends in rates of mental illness reveal a rapid increase of instance over the past decade, as illustrated in Figure 1.

The American Medical Association defines behavioral health as encompassing the following conditions: mental health disorders, substance use disorders, life stressors and crises and stress-related physical symptoms². For health plans and patients alike, often the first solution that comes to mind when addressing behavioral health issues is to focus on psychiatric interventions. Despite this assumption, mental and physical health are often intrinsically related and influenced by similar environmental factors. As a result, programs that utilize comprehensive Social Determinants of Health (SDOH) data to address behavioral health are often overlooked.

Behavioral Health and Social Determinants of Health

Social determinants, or drivers, are a useful indicator to identify factors which contribute to poor mental health in communities and individuals. Addressing health equity in all forms, including behavioral health, and SDOH factors are intrinsically related. Poor mental health can cause poor SDOH outcomes or vice versa. The National Library of Medicine³ notes that these outcomes are largely tied to food scarcity, inadequate housing, lower socioeconomic status and trauma among additional factors.

Expanding access to quality behavioral health services is a necessary component of efforts to address behavioral health and SDOH outcomes. The following indicators are associated with limited access to behavioral health services and present an opportunity for intervention:

• Health Care, including insurance coverage and provider availability
• Stable Housing – a significant contributor to mental stress
• Education, especially from an early age
• Income and Employment
• Social Support

Clinical systems are still assessing ways to measure SDOH factors to inform behavioral health policies as there are still shortfalls in assessing these metrics⁴. Ideally, health plans, providers and communities can partner to address these issues.

Approaches to Target Behavioral Health through SDOH

Understanding and targeting the causal factors of mental health related to SDOH is critical in enabling mental health equity. The importance of various social determinants and their continuous evidence of impact on mental health is a call to action for improved whole-person care. Housing and food access highlight the whole-person impact of SDOH on health:

Stable Housing

Inadequate and unaffordable housing can result in poor mental health⁵. Increased access to affordable housing and adequate living conditions present examples of interventions focused on SDOH that would directly impact mental health. Poor living conditions such as mold, lack of heating and dampness can impact both mental and physical health. Overall, a lack of affordable housing within a community causes increased rates of homelessness which can lead to even greater mental health issues and physical health risks. An intervention to offer housing programs to those with mental health illness or housing vouchers to access affordable housing are examples of efforts to drive change.

Food Security and Healthy Diet

Access to food and a healthy diet are intrinsically tied to physical health and wellness; however, evidence suggests that unhealthy eating is also a contributor to poor mental health. Having a whole-person approach to care presents a potential intervention. Individuals with illnesses such as diabetes are more likely to have depression, highlighting the correlations between mental and physical health⁶. Increasing food security by delivering healthy food to farmers markets, community gardens, corner stores or through home delivery offers alternative opportunities for individuals struggling with poor nutrition due to lack of access.

Evidence of successful programs continues to arise as health plans, providers and communities’ partner to address social determinants of health. Pyx Health’s Loneliness Assessment is an example of a successful intervention.

Pyx Health Loneliness Assessment

Providers can also look to interventions which work in conjunction with health plans to address behavioral health and SDOH outcomes. Pyx Health, based in Arizona, is a healthcare company which works with Medicaid and Medicare plans to support individuals experiencing loneliness. Their process involves identifying vulnerable members through SDOH screening tools and offering vulnerable members 24/7 support⁷. Members use the app to express their needs and are subsequently connected with resources within their health plan and community. The approach improves behavioral health outcomes and reduces stress on clinical health resources. Given the limited amount of multi-dimensional approaches which specifically address behavioral health utilizing social determinants of health, this approach serves as inspiration for similar interventions.

How ProspHire Can Help

Through ProspHire’s Addressing Health Disparities service offering, we strive to support our neighbors and clients to achieve more equitable whole-person care. Through population health assessments, targeted Social Determinant of Health interventions and innovative solutions to support behavioral health needs, we hope to enable positive change for your customers and our communities.

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¹ https://www.samhsa.gov/data/release/2020-national-survey-drug-use-and-health-nsduh-releases

² https://www.ama-assn.org/delivering-care/public-health/what-behavioral-health

³ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/

⁴ https://www.healthaffairs.org/do/10.1377/forefront.20210610.928520

⁵ The impact of persistent poor housing conditions on mental health: A longitudinal population-based study – PubMed (nih.gov)

⁶  Diabetes and Mental Health | CDC

⁷ https://www.pyxhealth.com/