Addressing social determinants of health has been labeled a priority by many studies and healthcare organizations, but that data can also be used by health plans to assess a member’s future risk.

Rick Ingraham, director of vertical markets for LexisNexis Healthcare, feels it’s up to analytics, informatics and professionals to make sense of social determinants data and direct health plans’ engagement efforts to where they can be the most effective. He laid out a path for this to happen in an interview with HealthExec at the Healthcare Financial Management Association (HFMA) conference in Orlando.

HealthExec: You mentioned health risk scores on social determinants of health (SDOH) as a priority for health plans—how would you assess their current ability to understand how those issues influence a member's future risk?

Rick Ingraham: There is fast-spreading recognition that social determinants of health are real and perhaps greater than initially understood. Studies released by organizations such the Robert Wood Johnson Foundation, Kaiser Foundation, Commonwealth Fund and American Hospital Association have all laid out some compelling facts as to their impact on current and future health if unaddressed. Unfortunately, I am afraid that too often such studies approach SDOHs as barriers to health access versus indicators of health risk that can be used for proactive patient outreach.

This mindset directly impacts a health plan’s ability to understand these issues. It is critical that informatics and analytics provide filters to take massive amounts of public socioeconomic records and proprietary data to carve out relevant health attributes that impact both current and future health and, then even further, rank-score the risks to provide a game plan for engaging patients with the kind of SDOH health risk profile that can be most directly impacted through proactive engagement.

Is the technology able to put that social determinants data to good use?

There are a wide variety of various engagement, like messaging, patient-communication digital and telephonic technologies that can be leveraged to effectively communicate with members or patients. The key is to leverage either 1) SDOH health attributes lists, previously clinically validated, or, preferably, 2) Risk-scored registries of patients/members based upon those clinically validated health attributes from which to then engage with patients.

What do providers need to improve upon to help payors identify, aggregate and analyze patients and members?

I think of this a bit differently. From a risk-bearing organization, traditionally the health plan, any and all insight into health risk stratification of members is welcomed. The challenge with the health plans is to help them realize there are more resources available to them than the always-go-to-claims system. The public and proprietary socioeconomic data that I referred to in my first answer can empower this SDOH risk insight into existing members and, more importantly, into members who have yet to submit claims. As a risk-bearing organization, the “Holy Grail” is a more proactive, effective and efficient member outreach program based on stratifications. Now, for the provider, they need not worry about helping payors identify, aggregate and analyze patients when they can do it themselves. The very same solution available to payors is available to providers. The challenge is this: When a provider is trained to diagnose and treat based upon patients that present for care, what incentive is there to reach out for those not yet presenting? The opportunity now, with value-based reimbursements and at-risk contracts, is to bring about a cultural change within the provider community, perhaps driven by their own financial executives, to staff for and execute outreach programs.

What's the most common mistake you see health plans making in terms of strategy, either short-term or long-term?

It is difficult to problem-solve age-old problems when leveraging the same data used throughout a health plan’s operations. It is time to redefine healthcare data. If it is accurate and understood, and can lead to conditions avoidance or improvement, it must be considered health data even if not found in the medical or claims record. This can require aggressive strategies to partner, to understand the holistic make up of members and providers, and engage every customer, provider, and employer group in ways that will redefine for them what the insurance experience means. Strategically, if risk-based contracts are to be executed with providers, health plans need to lead in consumer engagement strategies and then share their learnings with providers. Perhaps, this discipline share will contribute to health issues being addressed collaboratively rather than payor versus provider approaches.

I've heard you preach that patient and member engagement is at heart of surviving in the value-based care world—how does that change if the Affordable Care Act (ACA) goes away and health plans can return to some pre-ACA regulations?

That ship has sailed, as some say. The ACA should not be viewed as synonymous with patient engagement nor value-based care. It is important to note that discussions within the industry around patient engagement opportunities, the disincentives of achieving furthering care quality in a fee-for-service reimbursement model, and the opportunities for aligning care quality and outcomes with a fee-for-value reimbursement model have been taking place long before the ACA and are continuing. MACRA (Medicare Access and CHIP Reauthorization Act) further provides incentives to processes that are viewed as requiring better patient engagement. Indeed, the long-agreed-upon triple aim—of improved patient experience, improved health and lower cost of care view—addresses patient engagement as critical.