Alex Azar, secretary of the Department of Health & Human Services, made a surprising announcement earlier this month during a speech at the Hatch Foundation for Civility and Solutions when he said the agency wants to pay for services that address social determinants of health, the root cause of a large portion of U.S. health spending. Azar says social determinants are tied to the agency’s move toward a value-based healthcare system that delivers better outcomes at a lower cost. But will health plans be a part of the equation?

Social determinants of health (SDOH) are conditions in the places that people live, learn, work, and play that affect health risks and outcomes. Although many may consider SDOH as an abstract term, HHS head Alex Azar said that for millions of Americans it is a very tangible, frightening challenge.

“How can someone manage diabetes if they are constantly worrying about how they’re going to afford their meals each week?” Azar asked in prepared remarks.  “How can a mother with an asthmatic son really improve his health if it’s their living environment that’s driving his condition?”

For providers who understand the drivers behind the health conditions and want to help their patients, it is frustrating because they can’t write a prescription for healthy meals, a new home, or clean air, according to Azar. And even if they were able, there is no direct reimbursement model to pay for such services.

But that may soon change if Azar has his way. He says the federal government could spend less money on healthcare for the most vulnerable Americans if it did a better job of investing in their non-healthcare needs. His goal: to design models that connect them to services they need, including housing, nutrition, and other social needs, rather than a one-size-fits-all approach.

The Center for Medicare and Medicaid Innovation (CMMI) has already developed two models that address how the agency can better treat and prevent substance use disorder through a more holistic approach as well as a model that addresses behavioral and mental health conditions in children. He also teased that the industry should “stay tuned” as CMMI is looking into other programs that address SDOH in vulnerable populations. But that’s not all. He said the agency wants to consider SDOH throughout the Medicare program via Medicare Advantage.

“Because MA plans hold the risk for their patients and they compete for their patients’ business, they have an incentive to offer benefits that are both appealing to their members and that will bring down health costs—whether those benefits are traditionally thought of as health services or not,” Azar said. “The key is just that we need to give them the flexibility to do this, which we generally haven’t done. But starting next year, plans will now be allowed to pay for a wider array of health-related benefits, such as transportation and home health visits. Starting in 2020, we are going to be expanding that range of benefits even more to include home modifications, home-delivered meals, and more.”

These interventions can help keep senior citizens out of the hospital, he said, and shorten hospital stays. “We need to prevent disease not just by providing the right health services, but also the right holistic approach to prevention and well-being,” Azar said.

Industry reaction

Azar’s comments reflect the growing movement within the health care industry to address SDOH when caring for members/patients. Indeed, RISE will address the topic in January at two conferences. Joyce Chan, vice president, Medicare product, HealthFirst, will present a session that explores the direct relationship between addressing social needs factors and achieving company quality improvement goals at the 3rd Annual CMS Bid Bootcamp next month in Fort Lauderdale, Fla. And RISE will devote an entire conference, the 2nd Annual Symposium on Partnering to Address Social Determinants of Health, to the subject.

Jim Milanowski, president/CEO of Genesee Health Plan in Flint, Michigan, who will speak at the symposium, says the federal government’s interest is a step in the right direction, but there is still a long way to go.

Milanowski says HHS and CMS have undertaken initiatives on SDOH but most of the time the federal government gives the money to states to decide how they want to do the projects. “I think there is a lot of good intent. But how well the states are doing using those dollars for the social determinants seems, in my opinion, to be all over the place.”

Furthermore, payment reform and provider incentives must go hand in hand with these projects, according to Milanowski. There also must be better coordination among health plans, providers, and community-based organizations, he says. “It needs to be a full community approach. To tackle these issues we must work together,” Milanowski says.

Tom Lutzow, president and CEO, Independent Care Health Plan, says it’s about time the HHS takes the lead on this issue, but to make true change, many federal agencies need to align efforts and integrate existing programs with common objectives. For example, the U.S. Department of Agriculture oversees the Supplemental Nutrition Assistance Program, more commonly known as the food stamps program, and has certain work conditions that recipients must meet, but there are no requirements aligned to health. If a person has addictive behavior, the DOA has no requirement that he or she receive clinical care. If a person has diabetes, there is nothing that says he or she can only purchase meats and vegetables.

“Existing programs are not integrated with population health objectives,” says Lutzow, who also will speak at the SDOH symposium. “Somebody needs to rethink all of this and make sure the values of these programs are aligned to the goals of population health because they are probably not getting the bang for the buck from having programs that are not integrated.”

Even within the health care environment, there is a lack of integration, he says. For example, health plans must measure medication reconciliation within 30 days of discharge. But the government doesn’t want health plans to do it. They want physicians under contract with health plans to do it. Health plans must then enforce the contract rule or create incentives to do medication reconciliation within 30 days of discharge. But under MACRA and MIPs, he says, physicians must only pick six out of 275 measures and only one of those measures has to do with medication reconciliation.

“If we are serious about population health and cost control we would align around a common measure set and common outcomes for all providers across the entire system,” Lutzow says.

But to truly have member-centered care, he says the government must allow for flexibility because one-size-fits-all doesn’t work in that environment.

Garth Graham, president of Aetna Foundation, says Azar’s comments underscore the ongoing recognition of the importance SDOH play in health outcomes, policy, and general healthcare. However, he says it’s also important that stakeholders consider local input.

“All health care is local,” says Graham, the keynote speaker at the 2nd Annual Symposium on Partnering to Address Social Determinants of Health. Regardless of whether Azar heads this effort or someone from another federal agency does, Graham says nothing is going to happen until they look at what is happening in local communities.