MA – New Health Model Helps Identify Social Determinants

September 2017 ~

Massachusetts Medicaid administrator, MassHealth, is taking an innovative approach to control costs through implementation of a new health model that helps identify and address social determinants of health.

Social determinants, while rarely addressed sufficiently in the primary care environment due to a lack of data analytics infrastructure and unclear financial incentives for providers to tackle external socioeconomic issues, contribute to the billions of dollars spent on chronic disease management.

According to MassHealth, the Social Determinants of Health Model is a proactive approach to analytics, and by partnering the model with attractive provider incentives, has helped the state begin to address some opportunities for more savings and better patient outcomes.

Dr. Arlene Ash, a professor of quantitative health sciences along with her team from UMass Medical School produced the designed the model to allocate appropriate funding to providers based on the adjusted risk scores of their socioeconomically vulnerable patients. Using ICD-10 codes and administrative claims data, the model addresses two of the fundamental problems of analytics for value-based financial purposes.

The formula for the model was developed after looking at Medicaid enrollment data from 2013. Patients with costs that exceed $125,000 in 183 days were highlighted as eligible for provider-based incentives. The model also accounts for providers operating in challenging neighborhoods by using a “neighborhood stress score” that incorporates factors like average income and educational level, to allocate extra funding.

ICD-10 codes, according to Dr. Ash, offered a promising start for standardizing the social determinants of health, but very few providers were utilizing ICD codes that help identify social standings.

Ash explains, “Under this program, the answer becomes much clearer. A provider or an ACO can get an extra $600 or $700 per patient if we know that they’re homeless and likely to need more services to compensate for that. Payers will now be paying more money when this information is made visible.”

“For the payer, there is the question of how to collect data considered sufficiently reliable in order to modify payments based on it. And for the provider organization, the problem is identifying what data is important in the first place – and how to translate that data into knowledge for their own decision-making.” Ash continued, “Now that providers have some flags to identify people who are homeless or dealing with some sort of instability, and now that they are getting more money for these people because of their particular problems, maybe providers will try to come up with a systematic way to get these individuals into the right management programs to help them with their needs.”

Source(s): HealthPayerIntelligence; Leavitt Partners; MassHealth; SHVA HMA; Massachusetts Medical Society;