Medicare Advantage Benefits Expand Access to SDOH, Telehealth Services

Increased attention is being paid to treating the whole person, addressing social determinants of health and recognizing the value of virtual care.

Both the healthcare community and the people it serves are increasingly aware of the need to treat the whole person rather than isolated ailments and symptoms. Just as the various parts of the body are interdependent, and the body and mind cannot be separated, the individual does not exist in a vacuum, immune to his or her environment. Effective healthcare means considering all these factors as interrelated elements of one complex system.

Such an approach necessitates understanding and addressing conditions in the places where people live, learn, work and play—including factors such as food security, housing and income. These factors, known as social determinants of health (SDOH), can drive up to 60% of health outcomes, according to the Kaiser Family Foundation. By leveraging SDOH, healthcare providers can gain insight into patient populations and provider experience, improve patient health and reduce healthcare costs.

Medicare Advantage plans are adapting to the aforementioned realities.

These so-called Part C plans, offered by Medicare-approved private companies, are an alternative way for consumers to get hospital (Part A) and medical (Part B) insurance coverage. Popular options include health maintenance organization (HMO) plans, preferred provider organization (PPO) plans, private fee-for-service (PFFS) plans and special needs plans (SNPs). Most Medicare Advantage plans include drug coverage (Part C). According to the Kaiser Family Foundation, enrollment in Medicare Advantage plans has doubled over the past decade, with more than 24 million people enrolled in 2020.

Even before the arrival of the coronavirus, the Centers for Medicare & Medicaid Services (CMS) had expanded the definition of supplemental benefits to cover more nonmedical products and services that address SDOH. New Medicare Advantage criteria for 2019, as described in a study by PwC’s Health Research Institute (HRI), allowed those insurance plans to cover items such as air conditioners for people with asthma, healthy groceries for those on medically prescribed diets, home-delivered meals for those with compromised immune systems, and rides to medical appointments for those without transportation.

The 2019 rule changes “afford payers an opportunity to achieve reductions in costs, particularly for patients with manageable health conditions such as diabetes and heart diseases,” according to the HRI study. “Doing so, however, will require a greater investment in new data sources to track new kinds of information, rather than updating existing health records.”

Ideally, these new data sources should include claims records and information about SDOH, as well as data from at-home monitoring devices such as blood pressure monitors, connected weight scales and fitness trackers. Useful third-party data about the social factors impacting members might also include DMV, prison, dental and credit bureau records.

New CMS rule changes for 2021, as noted by PwC, include encouraging Medicare Advantage plans to expand their telehealth networks to specialty providers. The aim is to strengthen telehealth options in rural and other areas, in specialties such as dermatology, psychiatry, cardiology, ophthalmology, nephrology, primary care, gynecology, endocrinology and infectious diseases. According to investment and personal finance advisers The Motley Fool, “94% of Advantage plans will offer telehealth services to enrollees” in 2021. This makes it easier for more people, especially high-risk populations, to receive essential medical care virtually, while boosting reimbursements to payers.

It’s easy to see how increased reimbursements reduce payers’ healthcare costs. Less obvious may be how investments in new data sources, along with expanded coverage of nonmedical products and services, can help accomplish that same goal.

The answer, once again, comes down to interconnectedness and treating the whole individual. By addressing root environmental causes rather than merely symptoms—and by proactively focusing on prevention rather than staying in reactive mode—healthcare providers can stop problems before they start, or at least before they grow worse (and more expensive).

Similarly, in order to provide the best possible care, all those involved in an individual’s care benefit when they operate as one system rather than in discrete silos. Easy access to relevant and timely data, shared across divisions of specialty, is essential to helping care providers work together seamlessly, elevating the level of care while eliminating redundancies and unnecessary costs. Coordinated care makes a difference—whether that care is provided in person, virtually or by some combination of the two.

Efforts to build a more comprehensive view of the customer, share information, collaborate across disciplines and provide exceptional health outcomes are in everyone’s best interest. The fact that Medicare Advantage plans are being encouraged and enabled to do this on an increasingly larger scale can serve as an example for others across the healthcare industry.