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Thomas KS, Durfey SNM, Gadbois EA, et al. Perspectives of Medicare Advantage Plan Representatives on Addressing Social Determinants of Health in Response to the CHRONIC Care Act. JAMA Netw Open. Published online July 12, 20192(7):e196923. doi:10.1001/jamanetworkopen.2019.6923
How are Medicare Advantage (MA) plan representatives responding to new flexibility granted by the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act to address members’ social determinants of health through supplemental benefits?
This qualitative study with participants from 17 MA plans (representing >65% of the MA market) revealed that addressing members’ social determinants of health was important but reported 2 distinct approaches: creating supplemental benefits or supporting community-based organizations. Participants described complex decision-making concerning how to provide supplemental benefits, including a need for evidence, return on investment, strong community partnerships, and US Centers for Medicare & Medicaid Services guidance.
Enrollees in MA may have differential access to supplemental benefit offerings that address social determinants of health.
The passage of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act in 2018 allows Medicare Advantage (MA) plans, which enroll more than one-third of Medicare beneficiaries, greater flexibility to address members’ social determinants of health (SDOH) through supplemental benefits.
To understand MA plan representatives’ perspectives on the importance of addressing members’ SDOH and their responses to the passage of the CHRONIC Care Act.
Design, Setting, and Participants
This semistructured qualitative interview study conducted via telephone from July 6, 2018, to November 7, 2018, included participants from 17 MA plans that collectively enrolled more than 13 million MA members (>65% of the total MA market). Data analysis was conducted from September 18, 2018, to December 13, 2018.
Main Outcomes and Measures
Audio-recorded interviews were transcribed and then analyzed using a modified content analysis approach to identify major themes and subthemes.
Thirty-eight participants representing 17 MA plans varying in region, star rating, and size were interviewed. Analysis of interviews revealed 3 key themes. The first theme was that participants increasingly recognize the value of addressing members’ SDOH. The second theme was that participants had different perspectives on whether MA plans should directly address SDOH and how to do so. While some reported that they were taking advantage of the increased flexibility provided by the CHRONIC Care Act to design new benefits or partner with community-based organizations, others indicated that it was outside of their purview to directly address members’ SDOH. The third theme was that participants described complex decision-making around how to provide supplemental benefits, including a need for evidence, return on investment, strong community partnerships, and guidance from the US Centers for Medicare & Medicaid Services.
Conclusions and Relevance
These findings suggest that the changes in MA plans’ benefit packages in response to the CHRONIC Care Act and their efforts to address SDOH will vary. Therefore, it is likely that MA enrollees will be differentially affected by the implementation of the CHRONIC Care Act.
Social determinants of health (SDOH) may have a larger impact on individuals’ health and well-being than medical care.1 It is estimated that where people live, work, and socialize determines as much as 60% of their health, whereas formal medical care accounts for just 10%.2 Older adults who are socially connected, food secure, and financially stable and have easy access to transportation are healthier3-5 and have lower health care utilization.6-9 Thus, the health care system has an increasing interest in addressing SDOH as a way to decrease costs and improve health. This has been reflected in several recent US Centers for Medicare & Medicaid Services (CMS) initiatives.10-12
Medicare Advantage (MA), which enrolls more than one-third of all Medicare beneficiaries,13 has the potential to influence health by offering services beyond medical care. In MA, private health insurance plans are paid on a capitated basis to cover members’ health care needs. Thus, MA plans have an incentive to address their members’ SDOH to reduce unnecessary health care utilization and contain costs. Medicare Advantage plans have historically provided supplemental benefits that are not covered under traditional Medicare (eg, dental benefits, eyeglasses, gym memberships, meals after hospital discharge, medical transportation) to members. Until recently, regulations required that MA plans’ supplemental benefits be primarily health related and offered to all members. However, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, passed as part of the Bipartisan Budget Act of 201814 (effective 2020), allows greater flexibility in what benefits may be offered.
The CHRONIC Care Act was passed by Congress in a bipartisan effort to impel the Medicare program to be more responsive to the needs of beneficiaries with chronic illnesses.15 There were several key changes under the act. First, plans were given the opportunity to design supplemental benefits that “have a reasonable expectation of improving or maintaining the health or overall function”16 of chronically ill members and target these benefits to members at greatest risk. These benefits could include diverse services, such as meal delivery, cooking classes, home modifications to assist with mobility, personal care services, and many others.17,18 There is no requirement that plans offer these benefits, and as a result, there may be variation in how plans respond to these changes. In addition to expanding supplemental benefits, the CHRONIC Care Act waives the requirement that all members be offered uniform access to benefits, enabling more specific targeting of services to members who may benefit the most.
To our knowledge, very little is known about MA plans’ interest in taking advantage of the new flexibility for benefit design that the CHRONIC Care Act offers to address their members’ SDOH or whether barriers exist to providing these services as part of their plans’ benefit structure. Prior to the CHRONIC Care Act, some MA plans announced efforts to address SDOH. For example, Humana’s Bold Goal19 initiative includes several programs addressing healthy eating and social isolation. However, this and other MA plans’ initiatives from before the CHRONIC Care Act to address SDOH were funded through case management or with administrative dollars, as opposed to a formal benefit for members. As such, these efforts may have been somewhat limited. The objective of this article is to understand the perspectives of MA plan representatives on the importance of addressing members’ SDOH, the challenges they face in doing so, and their responses to the passage of the CHRONIC Care Act.
We conducted semistructured interviews with participants from MA contracts (referred to as plans). Plans were identified using purposive and snowball sampling approaches. We first recruited representatives from plans that we knew were knowledgeable about many of the topics of interest. Representatives then were either recruited or connected us with other appropriate representatives within their plans. Then, we asked participants for recommendations of other potential plans and participants. We purposefully recruited plans of varying size, quality, and geographic location.
We designed semistructured interviews to understand MA plan representatives’ perspectives on addressing members’ SDOH and responses to the CHRONIC Care Act. We drafted the interview guide and piloted it with 1 MA plan, making subsequent revisions to questions that were difficult to interpret or failed to elicit intended responses. We emailed the interview guide to participants in advance to confirm that relevant, knowledgeable plan staff were included in the interview. One of us (E.A.G.) conducted the interviews via telephone from July 6, 2018, to November 7, 2018. Interviews lasted approximately 1 hour and were recorded with participants’ consent. This project was deemed exempt from institutional review board approval by the Brown University Institutional Review Board because it was not considered human subjects research. We continued to recruit plans of various characteristics until data saturation was achieved,20 meaning that no new information or themes were observed through additional interviews. This study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.
Transcripts were analyzed using a modified content analysis approach to identify overarching concepts and themes.21-24 We first developed a preliminary coding scheme based on the questions in our protocol, then used an iterative process to add codes and refine code definitions. The resulting coding scheme reflected both the a priori codes and codes for unanticipated content.
At least 2 of us (E.A.G., J.F.B., E.M.M., S.F., and T.W.) coded each transcript. For each transcript, we discussed preliminary patterns and reconciled our interpretations. We kept a comprehensive audit trail that recorded ongoing team decisions, including selection and definitions of codes and discussion of emerging themes.22,25-28 Coded data were entered into the qualitative software package NVivo version 12 (QSR International) for data management. For anonymity of the participating MA plans, we identify organizations by numbers assigned for this study. Data analysis was conducted from September 18, 2018, to December 13, 2018. For additional details, see the eAppendix in the Supplement.
Interviews were conducted with 1 to 6 participants per plan for a total of 38 participants from 17 MA plans. Participant positions included presidents or chief executive officers, chief medical officers, government affairs officers, chief legal officers, directors of health policy, and various vice presidential roles. Participants had been in their positions for 1 to 30 years. Represented plans were both national and regional in scope, had a range of publicly reported CMS quality star ratings29 (scale, 1-5, with 5 stars indicating the highest quality), and enrolled from fewer than 50 000 members to more than 3 million members. Participating plans enrolled more than 13 million MA members in 2018 (>65% of the total MA market) (Table 1).
Our analysis found that representatives of MA plans believe addressing SDOH is important to improving the health of members and the health care delivery system. However, perspectives on the role of MA plans in addressing SDOH varied; while some participants reported that their plans are taking advantage of the increased flexibility in benefit design provided by the CHRONIC Care Act, others believed it was outside the purview of their plan to directly address members’ SDOH and were instead looking to collaborate with or refer to community-based organizations (CBOs). Participants reported their decision-making process for evaluating the many, sometimes conflicting, pressures they were weighing in responding to the CHRONIC Care Act and addressing SDOH, and some participants noted being cautious about moving forward in this area without clearer guidance from CMS. In this study, we discuss each of these themes and include illustrative quotes from interview participants.
Participants from MA plans recognized the importance of addressing SDOH for improving both member health and the larger health care system. Participants highlighted how addressing SDOH enables members to remain in the community and reduces health care costs. Participants also described SDOH as an increasingly discussed topic in MA, especially in response to legislative and policy changes like the CHRONIC Care Act. Representative quotes are presented in Table 2.
Participants from MA plans discussed multiple aspects of SDOH that are associated with their members’ health, especially in regards to keeping people safely in their homes and communities. These participants highlighted their desire to further efforts to provide meals and transportation beyond the previously allowed posthospitalization meals and medical transportation and also noted that legislative changes may allow them to view their members in a more holistic manner (organization 10) and attempt to address other important issues, such as social isolation, housing, and caregiver support. Representative quotes are presented in Table 2.
Participants from MA plans consistently discussed the importance of members’ social and lifestyle factors to their overall health and health care utilization. However, participants offered divergent perspectives on whether plans should directly address SDOH. While some were excited about offering new benefits or expanding existing services to address SDOH, others questioned the appropriateness of expanding their purview to include nonmedical care. Given these differences in perspectives, 2 distinct methods of providing SDOH-focused services emerged: (1) offering a supplemental benefit or (2) supporting CBOs and referring members to these organizations to receive needed services.
With the increased flexibility for benefit design made possible with the passage of the CHRONIC Care Act, some participants discussed their motivation to introduce a new benefit to address members’ SDOH and expand the services that they had already been providing. Participants also noted the value of the CHRONIC Care Act in allowing plans to design benefits that are targeted for specific subgroups of members. Some participants mentioned that offering a new supplemental benefit to address SDOH is a way to meet consumers’ needs and expectations; therefore, this could allow them to be more competitive in the marketplace and increase their membership. One participant believed adding a new benefit to address members’ SDOH was “the right thing to do,” particularly if it “makes sense from a quality and cost and member experience” perspective (organization 4). Representative quotes are presented in Table 3.
Other participants questioned whether it was the plan’s responsibility to address members’ SDOH and proposed that these needs might be “best served by providers or communities at large” (organization 12). Some mentioned the importance of a collaborative effort by plans, community agencies, and other stakeholders to fully address members’ needs. These participants preferred to address members’ SDOH by referring to and supporting CBOs. One participant, recognizing the strength of organizations in the community, 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 (eg, through community grants) to enable these organizations to provide needed services to members and help “community partners be sustainable” (organization 17). Participants highlighted being cognizant of not duplicating the efforts of CBOs that have existing expertise in addressing SDOH. Representative quotes are presented in Table 3.
Participants described detailed decision-making efforts regarding how best to meet members’ social needs. For plans that are considering addressing SDOH through a formal benefit, 3 overarching topics emerged as critical to decision-making concerning providing SDOH-focused services: financial return on investment (ROI), capabilities of community agencies to partner with plans, and guidance from CMS.
One major factor for deciding how to address SDOH that participants mentioned concentrated on ROI and whether a new supplemental benefit would result in savings. Given that the CHRONIC Care Act newly allows plans to target benefits to certain populations, plan representatives are also considering the complexities concerning choosing which groups to target for these supplemental benefits. Thus, participants expressed a need for more evidence on which benefits or services would be most effective in improving health outcomes and reducing costs and on determining which populations to target. Some plans mentioned the need for evidence that adding a benefit to address members’ SDOH would improve their star ratings, an important measure of MA plan quality that results in bonuses or penalties for plans. One participant described efforts to build that evidence base through pilot programs to eventually transform effective interventions into benefits. In making decisions about what benefits to provide, participants also reported examining research articles and engaging with members about their needs using focus groups. Participants also reported that members switching plans, members’ many needs, and varying operating margins from county to county made developing an evidence base particularly complex for MA. Representative quotes are presented in Table 4.
Participants discussed a number of decision points concerning whether and how to work with CBOs to provide services to address members’ SDOH. For plans looking to create a formal benefit and partner with CBOs to provide these services, some participants highlighted the importance of selecting a CBO partner that had the ability to scale services to a plan’s members; while plans may serve millions of members across states, CBOs frequently work on a significantly smaller scale. When selecting a partner, participants also expressed a desire to work with CBOs that had evidence of success and that are able to deliver (organization 4) in an effort to avoid members filing grievances and complaints that could affect the plan’s star rating. When deciding on whether and how to work with CBOs to provide benefits, some participants discussed the importance of partnering with CBOs that are willing to share the risk of providing a new benefit and building on existing relationships, given the challenges associated with developing new partnerships. Representative quotes are presented in Table 4.
In discussing their decision-making efforts, participants from MA plans highlighted questions they still had about the CHRONIC Care Act at the time of the interview (following the passage of the CHRONIC Care Act but preceding the publication of the final rules) and how it would influence their decision-making. One concern mentioned by multiple participants was how CMS would define SDOH in the final regulations. Participants described recent policy changes as “an evolutionary change, if not a revolutionary change” (organization 6), which require that plans carefully consider how to respond. Given the challenges identified, participants were cautious about moving forward in developing benefits to address members’ SDOH. Representative quotes are presented in Table 4.
Interviews with representatives from 17 diverse MA plans revealed that plans recognize the influence of SDOH on the health status of their members. However, participants did not uniformly believe that it was the role of the health plan to directly address members’ SDOH-associated needs. Participants described 2 distinct methods of addressing members’ SDOH: through a supplemental benefit or by supporting and referring their members to CBOs. Participants described decision-making concerning how to address SDOH based on ROI, evidence of success, and the strength of CBO partnerships. Lastly, participants noted a need for further guidance from CMS on how the CHRONIC Care Act will be implemented.
Medicare Advantage plan representatives reported seeking to address SDOH either by introducing a formal benefit or by supporting and referring their members to community agencies. To our knowledge, there are no data from MA or other types of health care plans assessing outcomes related to different methods of addressing SDOH. As we heard from participants, there is limited evidence to guide plans in determining the best way to meet their members’ needs, including which, how, and for whom interventions work. Building this evidence base may be challenged by the lack of standardized data collection and evaluation measures.30 If plans cannot evaluate impact, then resulting cost savings, quality improvement, and member satisfaction will not be well understood. Having this information is important, as participants in this study noted these are the drivers of their decision-making. Therefore, tracking and reporting the success of program implementation and evaluation is important to expanding effective, evidence-based interventions. Additional research is needed to track MA plans’ decisions, ie, whether and how to offer a supplemental benefit to address SDOH, and to understand the impact of their decisions on members’ SDOH and associated health outcomes.
Restructuring a plan’s benefit package to include supplemental benefits comes with risk. Plans will not receive additional funding to provide supplemental benefits, and their medical loss ratios will not be adjusted to account for additional costs. In addition, plans offering benefits to address SDOH may attract members with greater social needs. As current MA risk-adjustment efforts are imperfect in accounting for social risk,31,32 plans that offer these benefits may be unfairly penalized. Thus, MA plans are considering ways to provide benefits that produce improved outcomes in specific populations. As noted by participants, this evidence base is crucial to decision-making concerning which benefits to provide.
Given the challenges that may be present for plans to expand benefits, it is not yet known how many plans will take advantage of the CHRONIC Care Act, as all expansions of benefits are optional. In 2019, CMS began to offer plans new flexibility in benefits.33 Early quantitative work on this expansion found very little uptake of new services, with expansions concentrated in large, established, health maintenance organization–style plans.34 In this study, we did not observe any patterns in responses associated with plan characteristic (ie, location, star rating, or size). However, it is possible that larger, more established plans have greater resources to contribute to the creation of supplemental benefits or working with CBOs or that they have already positioned themselves to address this increasing need before the CHRONIC Care Act was passed. It could also be the case that smaller, more nimble plans may be more amenable to engaging with their members directly in an effort to meet their SDOH-associated needs rather than source these activities out to CBOs. It is also possible that health maintenance organizations are better positioned than preferred provider organizations to address SDOH, given the capitated payment structure in health maintenance organizations. Future research should track new benefits through time to understand the response to the CHRONIC Care Act and how it varies by plan characteristics.
Centers for Medicare & Medicaid Services has begun to address some concerns about how to pay for these supplemental benefits in their 2020 call letter35; however, it remains to be seen what the benefits landscape will look like in 2020. To address the concerns of the participants interviewed in this study, CMS will need to balance granting flexibility with providing guidance so that plans feel confident in developing new initiatives without fear of audit, sanction, or loss of their contract with CMS. Given the investment that plans must make in determining which benefits to offer (with limited evidence) and plans’ hesitations to innovate in the midst of changing regulations, it is possible that the initial supplemental benefits addressing SDOH that are offered in 2020 will be modest.
To provide more benefits to address SDOH, MA plans may learn from the experience of other payment models in expanding their service offerings. While, to our knowledge, there is no evidence to date of how MA plans can better address SDOH, flexibility has existed to address SDOH and other patient needs in patient-centered medical homes,36 accountable care organizations (ACOs),10,37-41 and Medicaid Managed Care.42-44 In particular, ACOs may face many of the same challenges as MA plans as they begin to take on more capitated risk, ie, the need for a strong evidence base that addressing SDOH may improve patient outcomes and reduce costs, the ability to find partners who can provide these services, and clear guidance from CMS about what is permitted.39 In a 2014 qualitative study38 of ACO perspectives on SDOH, ACOs, similar to MA plans, were interested in expanding these types of benefits but did not always know how. The Hennepin model,41 in which a Medicaid Managed Care agency partners with a hospital, a community health center, and the county department of health to better coordinate services, is often seen as a successful example of how organizations can address SDOH through community partnerships. The past successes of Medicaid Managed Care in addressing SDOH may be an even more relevant example to MA plans on how an insurer can best address these concerns.10
Our study has limitations. Given the qualitative nature of our study and sample of plans, results may not be generalizable. We selected plans of varying sizes, geographic locations, and quality, and in total, these plans enrolled 13 million Medicare beneficiaries in 2018 (>65% of the MA market). However, participating plans may differ in their perspectives from nonparticipants, and therefore, these results are not intended to represent the universe of MA plans. For example, given our purposive and snowball sampling approach, plans with a particular interest in SDOH or innovative programming may have self-selected to participate. Nevertheless, our study is among the first to report findings from interviews with MA plan leaders, to our knowledge, and provides insights into leaders of MA plans’ decision-making as to how, as well as whether they should, address members’ SDOH in response to the CHRONIC Care Act.
Findings from our interviews with participants from MA plans suggest that participants believe addressing SDOH is important. However, participants reported challenges in addressing members’ SDOH and apprehension about moving forward in this area without evidence and clear guidance from CMS. Therefore, it is likely that the introduction of new supplemental benefits in 2020 to address SDOH may be modest. Given the vulnerability of the population who may benefit from MA plans offering these expanded benefits, it is important that close attention be paid to how plans respond and the outcomes for Medicare beneficiaries and the US health care system more broadly.
Accepted for Publication: May 21, 2019.
Published: July 12, 2019. doi:10.1001/jamanetworkopen.2019.6923
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Thomas KS et al. JAMA Network Open.
Corresponding Author: Kali S. Thomas, PhD, MA, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Box G-S121(6), Providence, RI 02912 (email@example.com).
Author Contributions: Drs Thomas and Gadbois had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Thomas, Durfey, Gadbois, Meyers, Fashaw, Wetle.
Acquisition, analysis, or interpretation of data: Thomas, Durfey, Gadbois, Brazier, McCreedy, Fashaw, Wetle.
Drafting of the manuscript: Thomas, Durfey, Gadbois, Fashaw, Wetle.
Critical revision of the manuscript for important intellectual content: Thomas, Durfey, Gadbois, Meyers, Brazier, McCreedy.
Obtained funding: Thomas.
Administrative, technical, or material support: Thomas, Gadbois, Brazier, Fashaw.
Supervision: Thomas, Gadbois.
Conflict of Interest Disclosures: Drs Thomas and Gadbois reported grants from Meals on Wheels America during the conduct of the study. No other disclosures were reported.
Funding/Support: This study was supported by the Nonprofit Finance Fund Pay for Success Initiative and the funding awarded between 2015 and 2017 by the Social Innovation Fund; Meals on Wheels America; and the US Department of Veterans Affairs Health Services Research and Development (CDA 14-422 to K.S.T.)
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the US government.
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