Social Determinants of Health and Medicaid Payment Reform

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1 Social Determinants of Health and Medicaid Payment Reform Community Integration Leadership Institute June 2, 2016 Kate Breslin, President and CEO

2 Schuyler Center 2 Shaping public policy for people in need since Identify knotty problems. Undertake research and data analysis. Educate and advocate.

3 3 Guiding principle of NYS payment and delivery system reform initiatives is the Triple Aim: Improve patient experience of care (quality and satisfaction) Improve the health of populations Reduce the per capita cost of health care

4 Problems with the current system 4 Current system pays for inputs rather than outcome. Current system does not incentivize or reward prevention, coordination, or integration. Current system does not facilitate or support comparison shopping. Current system often does not value the individual/consumer/patient goals. Current system does not consider, measure, value addressing the social determinants of health.

5 Value-based purchasing or payment 5 In health care, VBP refers to a broad set of performance-based payment strategies that link financial incentives to providers performance on a set of defined measures. Public and private payers are using VBP strategies with the goals of improving quality and slowing growth in health care spending. In NYS, by DSRIP Year 5 (2019), all Medicaid Managed Care Organizations must employ VBP systems that reward value over volume for at least 80 90% of their provider payments or DSRIP dollars from CMS to NYS will be significantly reduced.

6 What s the opportunity? 6 If you can show that a particular intervention, service, or program results in improved outcomes, you can make the case that it should be offered/provided and that the entity providing it should be compensated. Value-based payments should include valuing what matters to individuals/consumers/patients (yet most current metrics reflect professional standards -- blood levels, number of visits or screenings, etc).

7 What s the challenge? 7 Defining, agreeing on, and measuring the outcomes. Figuring out cost and value. Social determinants of health are the factors that play the most important role in people s overall health. Our medical care system has, for the most part, not engaged in addressing SDH and, in many cases do not have the tools or resources to do so.

8 Why social determinants? 8 Theory behind VBP is that consumer/patient will benefit when health care providers and payers (managed care orgs) are aligned to share savings/costs based on patient outcomes; AND There is growing recognition of the FACT that the vast majority of premature mortality and morbidity is attributable to social, behavioral, and environmental factors yet the US spends most health-related money on health care, not the social determinants.

9 VBP Social Determinants of Health 9 NY s VBP Roadmap is the State s vision for implementing VBP. The Roadmap identifies importance of SDH in reaching the State s goals and promises that: the framework for value-based payment will maximally incentivize providers to focus on the core underlying drivers of poor health outcomes whether traditionally in the medical realm or not. (VBP Roadmap, p. 28, June 2015)

10 10 VBP Roadmap update SDH & CBO Recommendations 1. Providers/Managed Care Organizations (MCO) should assess/screen for patient social determinants. 2. Providers/Managed Care Organizations (MCO) should implement interventions to address SDH. 3. Providers/Managed Care Organizations (MCO) should develop and use catalogue of community resources. 4. Every VBP arrangement should include communitybased organization (CBO). 5. Metrics to track the success of SDH interventions. 6. Workgroup and process to consider children in VBP.

11 CDC - Social Determinants of Health 11 Economic and social conditions that influence the health of people and communities. These conditions are shaped by the amount of money, power, and resources that people have, all of which are influenced by policy choices. Social determinants of health affect factors that are related to health outcomes.

12 12 Identifying Effective Interventions SDH Categories Expanded Economic Stability Education Health and Healthcare Social, Family and Community Neighborhood and Environment Economic instability, poverty, and lack of employment Lack of education, educational disparities Lack of healthcare engagement Criminal justice involvement Substandard housing Homelessness, housing instability, and lack of access to affordable housing Lack of English literacy and proficiency Lack of accessible/ competent primary care Isolation and lack of family/community support Physical barriers in the home Food insecurity and lack of adequate nutrition and lack of access to healthy foods Lack of access to culturally competent staff Trauma Lack of transportation Lack of health literacy including cultural context Stigma and discrimination

13 Examples of social determinants of health 13 How a person develops during the first few years of life (early childhood development). How much education a persons obtains. Discrimination and social support. Being able to get and keep a job. What kind of work a person does. Having food, type of food. Housing status. How much money a person earns.

14 Things to think about 14 How to measure value? How to value the consumer s perspective? Screening for social determinants of health How do we make connections and build payment structures so that providers and communities have access to the tools they need to address social determinants of health which may not presently be known to them. Understanding and implementing evidence-based practices. Securing evidence for promising practices.

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