During the 2022 North Texas State of Reform Conference, a panel of experts outlined the need for Texas to establish more robust requirements for managed care organizations (MCO) to address social determinants of health.
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Stephen Palmer, Managing Principal for Health Management Associates’ Austin office, said the state’s comprehensive risk-based managed care should have language built into its RFPs that direct and establish more contracted services and protocols such as SDOH screenings during care assessments.
The Texas Health and Human Services Commission (HHSC) is already required by law to implement contract provisions allowing an MCO to offer Medicaid members certain medically appropriate, cost-effective, evidence-based services in lieu of mental health or substance use disorder services.
Palmer says there is more flexibility on the managed care side than in fee-for-service Medicaid that allows MCOs to propose value-added and in-lieu-of services (ILOS), as a covered benefit in their RFP that go beyond standard social services.
“Things like encouraging the MCOs to direct their providers to include the ICD-10-Z codes associated with social needs on their claims,” Palmer said. “In addition, we’ve seen some requirements for MCOs to provide training related to social determinants of health to their case manager service coordinators.”
Under current state policy, much of Texas’s SDOH work has been accomplished through pilot programs, according to Tara Kimbell, Strategic Director for Growth and Engagement at Amerigroup. Through these programs, Amerigroup has been able to reinvest some of its savings in quality related programs that focus on and address members’ needs.
Texas Medicaid Amerigroup worked with the Tarrant County Food Banks to set up food-as-medicine programs in CareMore Health clinics, a program that has been going strong for 6-7 years. Kimbell spoke to the success of establishing food pantry services in clinics for its members.
“We cannot encourage a diabetic to really stay faithful to taking their medication and testing their blood sugar when they’re hungry and they’re just putting in their bodies whatever they can get,” Kimbell said. “So along with that, we layered on some education as well. We brought the nutritionist from the Tarrant County Food Bank and one of the behavioral health fits at the clinic is we’ve got an isolated population. Loneliness is a big deal with a lot of our members. So we said, ‘Okay, well let’s put some programming together.’”
While many of the pilot programs are small in scope, they are highly impactful for the populations they serve. The panel highlighted the need for state action to pull these programs together in order to scale them up by fostering better coordination between MCOs, rather than having multiple contracts that manage their own independent programs.
“Creating these specific pilot projects that really impact [for example] women with gestational diabetes or [implementing] home-delivered meal programs,” Kimbell said. “When we look at some other attempts that we’ve had, and I know we’re not alone as a health plan, we have really tried to go that provider route.
We know that our members are in provider offices and incentivizing providers to do the SDOH screening, to make the referrals, and then to go as far as to closing the loop on referrals. We’ve had interest from providers in participating in that but there’s not a lot of longevity there and it’s because of the demands on clinic staff. It’s just difficult.”
Kimbell says most clinics have limited time and staffing to follow through and close the loop on social service referrals. CareMore Health, a primary care provider in the region, employs nurse case managers and community health workers who work to bridge the medical and social service gap. Bam Leach-Wongsaprome, Manager of Case Management at CareMore Health, said that his staff have been overwhelmed with the growing patient demand for services and that supporting those needs is unfeasible without more resources.
Through an initiative sponsored by the Episcopal Health Foundation, the Texas Association of Health Plans has been supporting an SDOH learning collaboration between MCOs. Kimbell, who has been a part of those collaborative efforts, says the best way to make SDOH part of medicine and medical costs are policies to push for more ILOS that can be paid for through medical claims.
“In California, they started with pilots, they started with home-delivered meals, pilots to support people with chronic medical issues,” Kimbell said. “They started with a doula pilot to support some of the birthing inequities, and then gathering the data, and the governor was very invested in wanting to see the data. But that’s what created these 13 in-lieu-of services that [California has] today and many of them are around home-delivered meals and around supporting people with chronic illnesses.”