Addressing Social Needs Can Impact Quality Performance & Payments

What impact can a member population with high social needs have on a health plan's quality performance and financial health? It can be significant.

Recent reports uncovered a correlation between a health plan's high social need population and negative impacts on quality performance measures, financial incentives, and payments.

Incorporating programs to address unmet social needs can positively impact health outcomes. It can also support higher-quality performance measures for payers of all types. From Star Ratings to CAHPS, HEDIS, and NCQA scores, performance measures can improve when members' social needs are adequately addressed.

Integrating social care and mature SDoH programs with quality improvement strategies provides a foundation for achieving health equity goals.

High social needs correlate with a negative impact on performance measures

Population health analysis found that Medicare Advantage (MA) plans serving markets with high social needs were 19% less likely to achieve a quality-based payment. The average Star Rating for plans with high social needs members was 3.94, and for low social needs members was 4.35.

Additionally, MA memberships with high social needs and low income tend to give lower CAHPS scores. MA plans with high social needs/low income had an average CAHPS rating of 3.08, nearly half a point less than MA plans with low social needs and higher incomes.

CAHPS correlates closely with patient experience and unmet social needs. For example, a clinical team may decide to put other needs on hold if they uncover housing instability for a patient living with multiple chronic conditions. Despite great clinical care, if the patient-provider interaction cannot help mitigate the immediate need, patients are more likely to reflect upon their experience negatively when surveyed.

Lastly, Medicaid NCQA performance also correlates to social-need levels for members under age 65. Only 3% of Medicaid plans with a high social-need membership achieved a 4-Star rating or higher.

Social risk scores and data can identify opportunities for necessary interventions

When considering all quality performance measures, teams must account for social risk scores as part of the population or individual assessment, which can reveal critical areas that require increased support, as well as inform targeted interventions and program strategies that can lead to improved reimbursement, incentives, and funding.

Organizations that capture, quantify, and use social risk data and indices can use that information to discover social needs and tell a member group's unique story. The data and patterns within the data provide compelling provocation to apply for grants, solicit additional funding, and attract value- and community-based partners.

Social risk data also provides the backbone for complying with new health equity requirements or value-based arrangements that rely on addressing health-related social needs.

Enhance services to address social needs based on social risk data, stratification, and individual assessment

Each health plan can have a varying role in addressing health-related social needs. Depending on its mission and position in the community, strategic directives, and financial models, some social needs may resonate better and add more value than others.

When health plan leaders assess how their current membership may affect the plan's quality performance and reimbursement, they can determine how best to address social needs while enhancing quality and satisfaction measures.

Offering member-centered personalized solutions is a critical part of using data to create change. When social needs are addressed, and performance measures improve, it can have a compounding effect. Star and NCQA ratings may increase, MA membership can increase, and new potential partners and providers can become more interested.

Improving health plan quality measures through social needs starts with data and analysis

Using an area-level social risk index can provide the foundation for assessing a health plan's membership. The RTI Rarity™ Local Social Inequity (LSI) score reveals vital characteristics of higher-risk populations, informs decisions about useful interventions to engage individuals, and supports NCQA requirements.

Moving from the member cohort to the individual member, payers can apply a risk score to all members and identify the risk of non-compliance or poor satisfaction scores. Stratifying the data across social needs and risk scores, race, and ethnicity complement existing data, provides indicators of the major health-related needs issues and possible disparities, and focuses efforts on bridging gaps in care.

The value of health plan quality improvement through addressing social needs

Health plans of all types—Medicare, Medicaid, MCO, or value-based contractor—can make the connection between high social need and quality performance scores. Then, they can enhance and tailor social need programs and community partnerships to not only tell the story with data but see the impact that meaningful programs can have on quality bonuses, incentives, and risk-adjusted payments.

Community partnerships tap into the proven success seen from leveraging community health workers, providing collaborative programs with community-based organizations, or contracting with non-profit community service organizations.

RTI Health Advance equips teams to assess and address social needs

We support organizations at the forefront of healthcare. Our team of experts covers the spectrum of issues faced by payers, providers, and vendors today. From health equity, data analytics, quality improvement, population health, and digital health technologies, we can help you achieve care, quality, and cost goals. Contact us to discuss how we can help or to experience a demonstration of the RTI Rarity tool.