NYHealth Hosts “A Conversation About Medicaid Coverage for Social Interventions”

The report, funded by NYHealth and Milbank Memorial Fund and commissioned by the Reforming States Group, serves as a guide for states to become smart purchasers of services for their Medicaid beneficiaries. It is particularly important because Medicaid is the largest purchaser of health care services, and as health care moves toward value-based purchases, the emphasis on health outcomes instead of clinical service outputs will require addressing the social determinants of health.

Ms. Bachrach, co-author of the report, set the stage for the discussion by posing a series of questions for states to consider in determining which social interventions should be covered by Medicaid. What populations should we focus our social interventions on, the very sickest or the at-risk? Which social needs do we choose to address? Which interventions, given that some are more successful than others, should be used and delivered by whom? How do we measure success?

These questions are important considerations because the social interventions outlined in the report are optional services. “States have the choice,” said Ms. Bachrach. “States never have enough Medicaid dollars, and New York is not unique. So, they are going to look at those questions and then they have to make those decisions.” Ultimately, it will be up to states to exercise their authority and act on their choices, concluded Ms. Bachrach.

Dr. Fish, representing the New York State Department of Health, shared four examples of how the Medicaid Office is attempting to address the social determinants of health: covered supportive housing; the Delivery System Reform Incentive Payment (DSRIP) program; behavioral health home and community-based services; and value-based purchasing. Dr. Fish discussed the State’s value-based payment roadmap, which outlines a plan to require providers in risk-sharing types of arrangements to include at least one intervention that addresses social determinants of health and to contract with at least one community-based organization. “Value-based purchasing arrangements will allow for much greater flexibility moving forward for the further incorporation of social determinants of health [interventions] across the State,” said Dr. Fish.

Dr. Beane, in her role as a Medicaid managed care payer at Healthfirst, spoke about the challenges of going from concept to contract. Dr. Beane put social factors in the context of many statewide reforms happening simultaneously in New York. She said that the focus on social factors “is what will link us in the MCO (managed care organization) world to the DSRIP world, and the infrastructure being built to the advanced primary care world.” Dr. Beane shared that Healthfirst has been exploring for a few years where, when, and how community-based organizations, community health workers, and peer navigators can actually help improve outcomes. “How we conceptualize this programming from the outset will help define the outcomes, the return that we receive in the end,” she said. She remarked that this is a critical point because it will help capitalize on new relationships with colleagues who are social service providers and emphasize prevention.

Mr. Pérez-Martínez, representing the only physician-led Performing Provider System in DSRIP, stressed the importance of changing relationships within neighborhoods. As part of the planning phase of its work, Advocate Community Providers mapped out the location of many of the individuals it serves. In doing so, it was able to identify concentrated areas of beneficiaries living in neighborhoods with a high burden of poverty, unemployment, and other social factors that negatively impact health. Furthermore, Mr. Pérez-Martínez emphasized the importance of creating a system that builds up, not burdens, primary care practices in these high-need neighborhoods.