Healthcare and health insurance plans are constantly evolving to better reflect the needs of society. One of the best examples of this constant evolution is the emergence and expanding understanding of social determinants of health (SDOH) as a primary contributor to health conditions and outcomes. Over the last 20 years, we’ve seen health insurance companies — and Medicare Advantage (MA) programs, in particular—develop and deepen a range of supplemental benefits to address SDOH.
In this article, we’ll talk about the meaning of SDOH, the impact of supplemental benefits on SDOH today, and how supplemental benefits will impact SDOHs moving forward.
What are Social Determinants of Health?
According to the U.S. Office of Disease Prevention and Health Promotion, “Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
While often not traditionally medical in nature, SDOH can impact health outcomes in a variety of ways. For example, individuals without easy access to grocery stores (or the money to afford and make healthier food choices) may not eat as nutritiously as those with more convenient access. Poor nutrition can impact and may lead to poor physical and behavioral health conditions, such as diabetes or obesity, difficulty managing complex health conditions and ultimately lower the odds of living a long or healthy life.
The University of Wisconsin Population Health Institute found that 40% of health outcomes were directly impacted by social and economic factors, while health behaviors (e.g., tobacco use, exercise) make up 30% and clinical care accounts for just 20%.
The Commonwealth Fund’s assessment of US Healthcare
The Commonwealth Fund ranked the healthcare systems of the world’s 11 high-income countries. The United States ranked last in every category except “care process.” The US achieved this low ranking despite spending a higher percentage of its gross domestic product on healthcare than any other entry on the list — almost 17%, or roughly twice what others spend.
The Commonwealth Fund identified four key areas that separate the U.S. from the top-performing countries on the list:
- Universal coverage and reduced cost barriers
- Primary care systems that provide high-value healthcare to everyone
- Reduced administrative burdens
- Investment in social services for citizens of all ages
This last area falls under SDOH, as The Commonwealth Fund includes childcare, community safety, education, housing, mental health, nutrition, and transportation benefits in the social services category. This gap underlines our need to address the SDOH issue, which the US has acknowledged in the form of supplemental benefits.
What are supplemental benefits?
One way MA plans are meeting the evolving needs of enrollees is through supplemental benefits. The Better Medicare Alliance offers this definition of supplemental benefits as they relate to SDOH: “Plans can now cover adult day care services, in-home support services, non-opioid pain management, food insecurity, home safety modifications, and transportation, allowing plans to offer benefits that directly address SDOH.”
In recent years, MA plans have expanded supplemental offerings to include a much wider range of services such as dental, vision and hearing care, as well as pest control, grocery delivery, and non-medical transportation. These services are tailored to meet the needs of individuals who face barriers related to their social determinants of health.
Popular offerings include:
- Fitness programs: Programs such as SilverSneakers – A popular community-based fitness program in many MA plans, SilverSneakers helps older adults improve and maintain their ability to balance and preserve physical mobility to reduce the risk of related accidents.
- Food security: This provides plan members with weekly meal deliveries. According to a recent study, those who received four weeks of post-discharge, home-delivered meals had significantly lower odds of 30-day rehospitalization and death.
- Transportation: This benefit helps MA plan participants keep their medical appointments through courtesy door-to-door transportation services. Depending on the benefit structure, the service is offered as one-way, or round-trip transportation with a maximum number of ‘trips’ per calendar year.
- Family and social support: Isolation, for many demographic groups, is a social determinant of health and is associated with mental health diagnoses, such as depression and anxiety. Services providing family and social support help remedy loneliness in members by providing free medical transportation, as well as weekly phone calls and wellness programs.
Supplemental benefits address the needs of specific demographics
In an August 2021 report, the Better Medicare Alliance announced that the number of MA plans offering supplemental benefits to address SDOH tripled in just one year. We believe that number will continue to increase
“As Medicare Advantage enrollment continues to soar — driven by diverse, medically complex, and at-risk beneficiaries — it is crucial that it be equipped with the tools to deliver whole-person care to this increasingly vulnerable population,” explains Kenneth Thorpe, the chair of the Better Medicare Alliance’s board of directors. “This report paints an encouraging picture of the significant investments Medicare Advantage plans and partners are already making in this space, with the number of Medicare Advantage plans providing SSBCI increasing more than threefold in a single year. Sensible policy changes can spur further innovation… this report offers a vision for a future where social needs are seen, met, and fully integrated into the health care experience.”
However, there are challenges to the introduction and adoption of supplemental benefits to impact SDOH. “The health care system recognizes the significant impact of unmet social needs on peoples’ health and wellbeing,” says Caroline Pearson, Senior Vice President of the National Opinion Research Center, the nonpartisan and objective research organization NORC at the University of Chicago. “However, we lack a systematic approach for identifying social needs, paying for interventions to address those needs, and evaluating the outcomes of these programs. With policy support, Medicare Advantage plans can play a crucial role in addressing these social determinants of health.”
Challenges facing supplemental benefits and SDOH
There are several barriers to SDOH innovations. Many national programs and their future are up in the air given changing economic and social policy positions.
The Better Medicare Alliance found three primary challenges to better serving the needs of Medicare Advantage participants:
- Disconnect with social services: Gaps in social services mean many social needs are not being met or monitored through healthcare services or newer supplemental benefits geared toward SDOH.
- Misalignment of incentives: Traditional funding models reward volume over value, so investments in SDOH-related supplemental benefits that cut downstream costs but aren’t reimbursed immediately can make for a hard sell.
- Siloed technology: MA providers and social services organizations typically have disparate systems, and these tech silos can slow down processes and lead to costly delays. Upgrades must be made to ensure we can identify members’ needs in real time, securely share SDOH data across social service agencies, and reliably track referrals.
The evolution of supplemental benefits
The value of supplemental benefits is now becoming more popular outside of MA plans. Supplemental insurance is an option for many people who want to cover lost wages or otherwise receive a cash benefit under specific circumstances.
Yet, there are varying perspectives on whether a traditional plan should directly offer benefits that impact SDOH or instead support Community-Based Organizations (CBOs) that provide those services.
For example, participants in one study recognized the strength of organizations in their plan’s community. They described developing a program that aggregates community resources and is used by care managers to identify services and make referrals for members.
Others discussed investing directly in CBOs (e.g. through community grants) to enable these organizations to provide needed services to members and help “community partners be sustainable.” Per the same JAMA Network report, “Participants highlighted being cognizant of not duplicating the efforts of CBOs that have existing expertise in addressing SDOH.”
Our prediction? Changing regulations will introduce new opportunities for businesses that provide the services to support new supplemental benefits, like mindfulness and stress reduction classes, ridesharing or meal delivery. But there will have to be further efforts to connect providers and consumers.
The future of supplemental benefits and SDOH
The future of SDOH-driven supplemental benefits is unclear. The Center for Medicare and Medicaid Innovation (CMMI) warns that voluntary models, like those that govern supplemental benefits, often present major disadvantages. CMMI Director Liz Fowler explains, “What we have learned from CMMI models over the past 10 years is that voluntary models [are] subject to risk selection, which has a negative impact on the ability to generate system-level savings.”
She added that providers who do not generate revenue using those models tend to exit the program, which causes a problem for CMMI, which has traditionally evaluated whether a model is successful based on its total impact on costs. As such, CMMI is exploring more mandatory models. “I realize those come with their own set of disadvantages,” said Fowler.
To offer the supplemental benefits that positively impact health outcomes, MA plans must build the infrastructure and apply additional investment to support offerings. These plans can advertise the supplemental benefits available when marketing their offerings, incentivizing plans to offer supplemental benefits that appeal broadly versus targeting only a smaller subset. Recent regulatory updates are encouraging MA plans to interact with their members to remind them of the benefits to encourage utilization.
Where will these funds come from? We may look to public policy as well as the private insurance industry for that answer. Supplemental benefits are growing in popularity, both within MA programs and in private health insurance plans.
As agencies scale back due to unprecedented economic pressures, we may see further increase in the popularity of supplemental benefits as more solutions will be needed to address both private and public options. The far-reaching impacts of supplemental benefits, while more difficult to immediately see or measure, will likely continue to drive health plans to leverage these benefits as crucial measures to address SDOH. While costing more initially, supplemental benefits may serve to reduce or control increasing health care costs related to comorbidities with the added benefit of improving the quality of life and health outcomes later in life.
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