Social determinants are forever changing health insurance

Steven Loeb · October 26, 2019 · Short URL:

New companies, and the incumbent players, are expanding the idea of what insurance should cover

When Vator holds its latest healthcare salon, called The Future of Health Insurance, on Nov. 14 (Get tickets here!), one of the topics that will inevitably come up is how health insurance companies are beginning to put a greater emphasis on what are known as the social determinants of health.

The CDC describes social determinants as, "Conditions in the places where people live, learn, work, and play [which] affect a wide range of health risks and outcomes."

The idea is that our health is more than what just happens in the four walls of the doctor's office; that it’s the rest of our lives, from what we eat to how we sleep to our social interactions, even our access to transportation, that will determine how healthy we are in the long run. While it's still relatively early in this shift, the social determinants of health are already thought to account for 80 percent of our overall health.

While this may not be a revelation for most of us, since we obviously don't spend most of our time in a doctor's office, it seems to be a major breakthrough for the healthcare industry, health insurance companies included.

That's why a number of these health insurance companies are finally expanding coverage to include a number of things, from groceries to Lyft and Uber rides to gym memberships, and more. What better way for health insurance companies to keep people out of the doctor's office, and therefore keep costs down than to try to keep people healthy?

The expanding idea insurance coverage

Health insurance is not an industry that is typically known for being innovative, especially when it comes to the incumbents; yet, the big insurance companies are already embracing these new types of coverage. 

For example, Blue Shield recently launched a pilot program called rideQ for some of its members in the Sacramento area to get rides to their doctors’ offices and healthcare locations; Cigna, meanwhile, has begun offering benefits such as an air conditioner in some plans in Texas, as well as transportation benefit to places of worship and grocery stores and adult care. 

“We’ve heard, and we’ve known that transportation is a barrier to care for many years, both from our members and patients, and then also from physicians. There’s some funding in Medi-Cal for some of our patients and members to have access to it, but not our commercial business, not folks who are on Medicare and other programs. So, we’ve known that this has been an issue for a while, and providers have told us that this is something that prevents people from showing up and actually getting care that they need,” Peter Long, senior vice president of Healthcare and Community Health Transformation, Blue Shield of California, told me in an interview. 

These types of services also fit into what the company is doing around telehealth and e-monitoring, he said. The idea is to try to get a more holistic view of a patient’s health, even when they’re outside of a doctor’s office. Knowing what’s happening in a person’s life can offer clues about how they need to be treated. 

“We believe, and there’s great evidence of this, that so much of what influences our health happens outside of the medical care system, so we want to begin to address that as well. How do you get greater access within medical care, but then how do you address things that are happening in people’s lives that are influencing their health and wellbeing?” he said.

"To the question of what is care and how do we define it: it’s not going to see a provider, or just going in person inside the four walls. So, rideQ is one aspect of that, and it’s addressing a real barrier for individuals and families about accessing the healthcare system as it exists today."

Cigna is also trying to capture that holistic view of the patient, Brent Sanders, General Manager of Medicare Advantage at Cigna, told me. 

"Our mission is around improving the health, wellbeing and the peace of mind of the individuals who we have the privilege of serving every day, and clearly that goes beyond some of the more traditional healthcare components. It really does weave in the full body and mind. We think there’s an important role that the doctor’s office plays, but in our desire to provide more choice to customers around affordability and personalization, it’s important that we continue to evolve into meeting the needs of those customers, wherever they are, wherever they have those needs," he said.

"From a Medicare Advantage perspective, we see the aging in of almost 10,000 individuals daily into Medicare eligibility, so there’s an evolving need there, in particular. Some of those needs are more traditional, like access to care, but then there are some of the benefits we rolled out over the last couple of years, such as meal plans for individuals that are discharged from the hospital setting, making sure that they’re getting access to certain benefits that enable them to fully recover. We’ve also made sure that there's an active access to the doctor’s office or hospital settings with transportation. And, in certain settings in 2020, we’re making incremental investments to test and learn how to expand those benefits to locations that are non-medical in their nature, so even places of worship and grocery stores. Things along those lines.”

Government's role in rethinking 'health'

In addition to the health insurance companies changing their thinking about what constitutes health, a similar, and equally as important, change is also happening on the government level, particularly from the Centers for Medicare and Medicaid Services (CMS). That is what is allowing these companies, as well as newer entrants into the market, such as Alignment Health, to be able to offer these services as benefits. 

“Social determinants of health has really been the topic for the last several years, and CMS has put in place more flexibility in how organizations are able to file it in a benefit package,” Dawn Maroney, consumer president at Alignment Healthcare, told me.

“We wanted to address things like meals, loneliness, depression, and then activity related to staying healthy through a wellness rewards type program. There were things we could do for members, but we really couldn't promote it to new membership coming in, file it to CMS in a bid and put in a package where CMS would look at it and approve it,” she said.

Given the changes in rules earlier this year, the company will be able to offer services more broadly to the Medicare population. That includes a variety of benefits outside of traditional healthcare, including Alignment's ACCESS On-Demand Concierge program, which gives members a dedicated concierge team, and its Black Card program, which consists of a debit card that can be used for qualified items, such as groceries at 50,000 retailers, as well as transportation to appointments through Uber and Lyft, and companion care. 

The company is also starting a program called "Grandkids On-Demand", where college students assist member in non-medical tasks, such as household chores, as well as its Care Anywhere program, where the company provides its members with home visits.

“There’s a recognition in the industry that it goes beyond the traditional body, and really incorporates the mind. Cigna has done a loneliness study that validates that across different age spectrums, the social component, the environmental component is a really important part of health,” said Cigna's Sanders.

“As an organization, we have been continuing to invest, and CMS has been a really good partner in opening up and providing more flexibility to health plans last year, for 2019. So, we took a step into that, making sure we were investing in testing and learning. We’re increasing that for our 2020 offerings that we just rolled out for beneficiaries. It is really orienting around the acknowledgement that the environmental, the social, the mind and body as a whole, is an important part of care for individuals holistically.”

Personalizing care

It’s not enough to just offer patients these types of expanded benefits; the insurance companies have to also understand what it is about this specific person's life that needs to be changed to make them healthier. That kind of information then allows these companies to better personalize the plans, making it more likely for patients to take advantage of these services. 

Knowing what each person wants, or needs, is not always as apparent as you might think, said Blue Shield's Long, despite an influx of data coming from personal devices, including Fitbits and Apple Watches.

"The technology is allowing us to personalize both healthcare and public health, or how we provide health to folks. It’s allowing us to pinpoint it. What we’re trying to do, as a plan, is to make it make sense since, a lot of times, we can just be guided by technology. We can monitor someone’s heart rate 24 hours a day, even if they're basically healthy, through their Fitbit or Watch, but it’s unclear that that information actually improves their health or, frankly, improves their care,” he said.

“The technology is challenging the healthcare system, and particularly health plans, to figure out how to make sense of this information and actually use it to provide better care for people, and to improve their health. That’s the intersection: technology is forcing the conversation, and forcing us to think differently about what produces health. Then our challenge is how to make sense and add value to this new ecosystem that’s emerging.”

Blue Shield’s approach is to combine take that technology and data and then combine it with a healthcare advocate; the company has partnered with a number of local organizations who are on the ground, giving them better insight into what’s happening in the community, and with individual members. 

“We believe that’s the right starting point because then what we’re going to do is customize the solution to what people actually need, rather than our perception of what they need. We can think that food insecurity is their number one issue, but in reality the much more pressing issue for them may be transportation or it may be trauma, it may be violence in their home, and if we take the approach of high tech, high touch, where we’re engaging with them, building trust, and trying to engage with what their properties are, with a comprehensive set of resources in that community, we think that’s the best way to produce a set of benefits or services that is customized and meets their needs,” Long said. 

“We think that’s better than us trying to guess what’s happening and trying to ‘fix’ these underlying issues. Just like you go to see a cardiologist, we think that we can pinpoint that it’s food insecurity, social isolation, transportation issues, and then how do we put together a package of services and have them be integrated that really does meet that person’s need to allow them to achieve their full potential?"

More personalization will lead to increased utilization, said Alignment's Maroney, and a big part of that has to do with incentivizing people to actually use these services. 

“We’ve made it so members have to go into a store to use their card, and they’re pretty excited about it and it’s immediate. So, we’re able to see what they’re grabbing and buying within the hour, and that helps us navigate different types of programs to keep the senior population more active and involved,” she said.

“A healthier, more active person may want rewards; how do we motivate them to go in and see their doctor and do their annual physical? How do we motivate them to go get their flu shot and/or look at programs? So, we have a rewards program that does that, and part of that is not only just a gift card but we’re also navigating an Apple Watch program that we’ll buy for them and help them navigate it. It may not connect on a formal level to Apple as a whole at this point but we will help them and we can connect that to a Grandkids on Demand on how to use that watch, so we’re connecting all our programs.”

One of the added benefits of personalizing care in this way, Cigna's Sanders told me, is that it actually winds up creating a better relationship between the insurer and the patient, as the patient feels like they are being listened to, and that they're getting value out of their insurance.

"People are looking to ensure that they’re getting value, or receiving value, so that’s part of our proactive outreach as well: ensuring there’s clarity of understanding of benefits and encouraging individuals to engage in their consumption of healthcare. That can be around preventive programs for health risk assessments, or some of the dental care, routine physicals, medication adherence, things along those lines. We think we offer a very positive experience and we very recently had a customer net promoter score study performed where we continued to show an uptick in customer experience,” he told me.

“Certainly the healthcare industry as a whole has something of a challenge when it comes to net promoter score and customer experience, so we look at that in the context of a consumer’s experience generally and we’re continuing to make meaningful progress relative to that. That’s an area of focus for us as an organization, to make sure that we are providing good experience. So, part of it is the benefits but part of it is the services and capabilities."

The future of health insurance

The social determinants of health are only just now starting to be thought of as healthcare, so this is only the beginning of a major sea change in how healthcare is going to be delivered and covered. For the insurance industry, this represents a major opportunity over the next number of years.  

"We have tested, evaluated and found a set of interventions, innovations that fundamentally improve a person’s health and wellbeing. We, at Blue Shield, are implementing them at scale and they have moved from being an interesting pilot to part of our core business,” said Blue Shield' Long.

“Beyond that, it may be in more than five years, though I’m ambitious and optimistic, they become the standard for healthcare. Yes, we are dedicated to our members and to make sure they have the best experience and the best health outcomes that are affordable, and we are committed to driving and seeing this become the standard of care for all. That’s our ultimate vision, to influence our colleagues across the state. We have a lot of ambition.”

For Cigna, the "focus is on meeting the needs of the individual through the affordability and personalization and enabling them to make choices over that lifetime," said Sanders.

"Whether it starts with our commercial solutions, and, ultimately, into our Medicare Advantage solutions, we think, as an organization, that we’re well positioned to do that,” he said. 

“It’s in the context of body and mind, meeting the full needs of the individual and ensuring they have a healthy lifestyle and can live a long, healthy life. We’re one of the few organizations in the industry that can offer that type of a solution to individuals, and, as it relates specifically to Medicare Advantage, there are a lot of ongoing investments and capabilities and solutions and innovations to meet some of these needs. Social determinants of health, in partnership with CMS, is certainly an area we’ll be investing more in in the context of that body and mind orientation.”

For Alignment, these services allow the organization to take some of the pressure off the doctors themselves.

"I’d like to get to a place where if we’re working with groups, and the access is not at the level it should be, we will be able to offer individuals access outside of that system. That means, for example, building more on the Care Anywhere program that we have in place with our own doctors that work for us. We have phenomenal groups, but if they have such a large number of patients then we want to be able to help them out by offering additional services," said Maroney.

The really interesting aspects of this, though, is that the possibilities for what might be covered by insurance are potentially endless; anything that improves a person’s health outside of the doctor’s office is a potential future benefit.

“From a packaging standpoint, I really want to get to something with pets, and how do we cover pet care or pet support when they need to go to surgery and they’re living alone? Because we see that all the time, people don’t want to go anywhere because they have their pet. That’s an area we’ll be looking at next," she said. 

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