BeneLynk Submission to OMB RFI: Methods and Leading Practices for Advancing Equity and Support

Recently, the Office of Management and Budget of the President of the United States put out a formal Request for Information on the following topic: “Methods and Leading Practices for Advancing Equity and Support for Underserved Communities Through Government.” Writing on behalf of BeneLynk, Sean Libby submitted the following detailing our position that to move our nation forward in addressing SDoH there are steps which need to be taken:

1. We must establish and codify a comprehensive list of SDoH ICD-10 codes

2. Managed care organizations serving Medicare and Medicaid recipients must be encouraged to systematically document SDoH barriers at the individual member level

3. CMS must use the levers available to it to incorporate these now clearly defined SDoH barriers into the compensation and measurement of managed care plans

It is only by effectively documenting SDoH barriers, and reflecting the health realities that they impose that CMS can help to improve the lives of historically under-served populations. You can read the full response below:

Response to:  Methods and Leading Practices for Advancing Equity and Support for Underserved Communities Through Government

Author: Sean Libby, President, BeneLynk.

I write the following in my capacity as President of BeneLynk (www.BeneLynk.com), a national social determinant of health (SDoH) advocacy company that serves members of Medicare Advantage and managed Medicaid health plans. Our mission is to give managed care organizations the SDoH information they need, while giving their members the professional advocacy they deserve.

Social determinants of health — including socio-economic factors and physical environment — have been estimated to impact as much as 50% of an individual’s health status[i]. For historically under-represented and under-served communities, SDoH barriers often prevent individuals from living their healthiest lives, creating preventable ER visits, and deteriorations in chronic conditions. Significant progress has been made in assisting these populations by managed care organizations. This effort can be traced back to the turn of the century with the first broad implementation of “dual eligible outreach” programs. These services sought to assist low-income Medicare recipients with applications for Medicaid programs – in particular the under-utilized programs known as the “Medicare Savings Programs.” These advocacy services arose to provide members with information about under-utilized programs and assistance with applications.

To meaningfully impact SDoH barriers a necessary first step is establish mutually agreed upon standards for documenting these barriers. In the healthcare arena, this means ICD-10 codes (ICD-10 referring to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems). To this end BeneLynk asks the Department of Health and Human Services, as well as the Centers for Medicare & Medicaid Services (CMS) to continue to grow the depth of ICD-10 codes for SDoH and to encourage wide adoption of these standards including in Electronic Medical Records. We commend CMS for its efforts to use these SDoH ICD-10 codes – commonly referred to as Z-codes. However, there remains significant work to be done to expand this code base to adequately represent all SDoH barriers. We strongly support the adoption of the wider range of SDoH ICD-10 codes proposed by the American Medical Association and industry-leader UnitedHealthcare. BeneLynk further supports the efforts of organizations such as The Gravity Project to set standards for interoperability of SDoH information in electronic health records (EHRs).

But documenting SDoH barriers is not enough. To address inequity in healthcare delivery it is necessary to incorporate SDoH information meaningfully into (among other areas) the mechanisms which compensate and measure the managed care organizations who deliver Medicare and Medicaid. Here we are addressing OMB Input Area #3 “Procurement and Contracting. Approaches and methods for assessing equity in agency procurement and contracting processes.” To meaningfully impact health equity, the unique challenges faced by historically underserved communities must be systematically represented and accounted for in the CMS contracting and measurement processes.

To achieve this goal in Medicare Advantage (MA), we at BeneLynk believe a two-pronged approach is warranted:

1. Incorporate SDoH ICD-10 codes into the HEDIS measurements that underlie STAR ratings. The function of STAR ratings is to measure the effectiveness of Medicare Advantage plans in delivering services. However, these measures are frequently adversely impacted in plans that disproportionately serve low-income members with a higher volume of SDoH barriers. A presumably unintended consequence of this reality is a disincentive for MA plans to design plans to attract and serve low-income individuals.

2. Incorporate SDoH ICD-10 codes into risk adjusted capitation. For decades, CMS capitation for MA plans has been increased for members who are dually enrolled in Medicare and Medicaid. This increased premium reflected the historically higher utilization on healthcare services by lower-income individuals who likely have faced and continue to face SDoH barriers. The logical extension of this methodology is to develop a system whereby SDoH barriers are systematically identified, and MA plans are encouraged to provide enhanced services to reduce healthcare inequities.

Similarly, in Managed Medicaid SDoH barriers can be incorporated into the relevant capitation paid by state agencies, as well as the risk adjustment models used by most states and state specific Pay for Performance metrics. We recognize that this contractual relationship is often beyond the purview of the federal government generally and CMS specifically. However, we at BeneLynk encourage CMS to work with state Medicaid administrations on programs to identify SDoH barriers and to incorporate services addressing those barriers into the premiums paid to Medicaid managed care organizations.

Addressing health equity requires commitment to identifying the challenges faced by historically underserved population, systematically quantifying those challenges, and then using all available levers to make a positive impact.  BeneLynk commends the Office of Management and Budget, Executive Office of the President for its commitment to pursuing this laudable goal and appreciates this opportunity to offer our suggestions.

About the Author

Sean Libby has been an advocate for seniors, people with disabilities, veterans, and individuals with low income for over 19 years. At BeneLynk, we are committed to helping managed care plans to deliver superior Social Determinant of Health solutions to their members. We are always looking to learn more and would like to hear your ideas on how best to assist members in need. Drop us a note at Sales@BeneLynk.com.

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[i] Source: County Health Rankings & Roadmaps, a collaboration between the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation, 2014