Addressing the Social Determinants of Health in Medicaid
December 4, 2017
I recently had the special opportunity to attend the Institute for Medicaid Innovation’s Annual Conference in Washington, D.C. This year’s theme, Addressing Social Determinants of Health in Medicaid, sought to create a dialogue around this increasingly popular topic, with a special focus on practical examples of implementation and innovation. One of the prevailing themes that emerged from the conference was that addressing social needs through the health sector is not a new idea, though funding and delivery models to support this work have not kept pace with need.
Rebecca Onie, keynote speaker and Co-Founder and former CEO of Health Leads, kicked off the conference by framing social determinants of health (SDOH) work historically. During the social movements of the 1960s, the pioneers of the community health center movement in the U.S. were already addressing health and social needs in tandem. Two of these pioneers, H. Jack Geiger and Helen Barnes, developed a health center model in Mound Bayou, Mississippi which addressed the roots of poverty by drawing on both local resources and federal funding, with the goal of empowering patients and the surrounding community, and providing evidence that addressing SDOH yields medical benefits.
In the past decade, Onie’s non-profit organization, Health Leads, has gained national attention for its work in creating what they describe as “sustainable, high-impact and cost-effective social needs interventions that connect patients to the community-based resources they need to be healthy – from food to transportation to healthcare benefits." In fact, the model has been labeled as an innovative delivery approach by many, though as Onie pointed out, the Health Leads model is not as innovative as it has been described. Further, despite the fact that Dr. Geiger was reprimanded by federal authorities for using Medicaid prescription funding to purchase food for his malnourished patients, Onie described that the idea of using health dollars to pay for social needs is not in fact controversial. Research conducted by Health Leads and the public affairs group Civitas demonstrates that when asked to allocate $100 to purchase health in their communities, Americans of varying political affiliations, race and ethnicities, genders, and geographical locations all similarly prioritized social needs, such as housing and food, in their spending.
Onie ended her address by introducing one of the fundamental questions of the health sector today. She noted that across sites where Health Leads operates, only a handful of resources account for as many as half of all successful resource connections for patients. This illustrates the sparse and inequitable community resource landscape in the U.S., and poses the fundamental question that conference participants wrestled with for the rest of the day: what is the health sector’s responsibility in addressing social needs?
Indeed, the difficulty of addressing social needs once they have been screened for and identified was a theme that emerged in the first panel of the day, titled, “Innovative Approaches in Addressing Social Determinants of Health in Medicaid.” Panelists from North Carolina, Missouri, Michigan, and California described promising new programs, such as an enhanced crisis response system utilizing an integrated approach for the provision of mental health services, a prevention and screening system for identifying risk factors correlated with child abuse or maltreatment, a telephonic screening program for identifying social needs among Medicaid beneficiaries in a rural area, and a housing for health partnership in a large urban setting. Every panelist acknowledged barriers, however, once a social need had been identified, there were often either insufficient resources at the MCO or community level to address the need or to confidently refer out a patient.
Perhaps unsurprisingly, the next panel of Medicaid plan CMOs were posed the question, “What is the responsibility and ability of MCOs to address social determinants of health?” The unequivocal answer among the CMOs was that the responsibility is clear though the ability is currently challenged by multiple factors, such as rigid Medicaid funding streams and reimbursement regulations, siloed administrative structures at both the local and state level, diversity in resource landscapes by geography, varying levels of political will, and overwhelming need. Once again, participants voiced a sentiment of innovation exhaustion. While RFPs for Medicaid MCOs from state governments repeatedly ask for companies to compete against one another in bidding for contracts with innovative approaches, conference attendees reinforced the message from Onie’s address earlier in the day: health leaders have known for decades how to address SDOH. SDOH can be addressed by screening for needs and connecting patients to resources; which as many pointed out, is not an innovative idea.
In the last panel of the day, “Medical, Dental, & Social Health Integration in FQHCs,” participants were presented with practical examples of integrated care at the clinic level. Findings from two studies identified meaningful medical cost reductions among patients receiving dental care compared to patients who did not receive such care. The savings were observed among patients with chronic conditions, such as type 2 diabetes and heart disease, and included statistically significant reductions in hospitalizations, with the largest medical savings observed among members who were non-compliant with their disease management programs.  These findings speak to the potential for both increased quality and decreased cost of care when patients’ needs are met comprehensively.
Finally, the Community-Centered Health Home (CCHH) Demonstration Project in Louisiana sought to explore an answer to the question posed by Onie earlier in the day: how can the health sector engage with the inequitable community resource landscape in the U.S.? The CCHH model utilizes an inquiry, analysis, and action framework to “guide health care organizations and their partners in the use of data to understand and prioritize community needs, and work together to create community change.”  These models, which actively engage health sector actors in creating change at the community level and outside of the clinic environment, provide an example of what addressing SDOH could look like in the future.
At the close of the conference, attendees were left with some exciting examples of programs which strive to reach outside of the boundaries of the traditional health system and into the communities where individuals live, work, and play. While there were still questions regarding mechanisms for integrating and financing health and social service provision, what was evident was the will and passion of the attendees for addressing the social determinants of health in their communities, which will continue to lead to an even richer conversation at next year’s conference.
 Our Vision | Health Leads. (2017). Health Leads. Retrieved 1 December 2017, from https://healthleadsusa.org/about-us/vision/.
 For more information on these studies:
UnitedHealthcare. (2013). Medical Dental Integration Study. UnitedHealthcare. Retrieved from https://www.uhc.com/content/dam/uhcdotcom/en/Private%20Label%20Administrators/100-12683%20Bridge2Health_Study_Dental_Final.pdf
Jeffcoat, M., Jeffcoat, R., Gladowski, P., Bramson, J., & Blum, J. (2014). Impact of Periodontal Therapy on General Health. American Journal Of Preventive Medicine, 47(2), 166-174. http://dx.doi.org/10.1016/j.amepre.2014.04.001
 Louisiana Public Health Institute (LPHI). (2017). The Community-Centered Health Homes Demonstration Project: 2017 Report. Louisiana Public Health Institute (LPHI). Retrieved from http://lphi.org/wp-content/uploads/2017/10/CCHHFinalReport.pdf