Social determinants of health (SDoH) complicate engagement and present new, unique barriers to overcome in order to establish meaningful connections. But what are the key factors to consider to achieve better health outcomes with the Medicaid population?

To answer this question and to understand the full scope of SDoH we talked with Sara Ratner, Icario Medicaid Advisory Council Member, to dive deeper into the astonishing impact of SDoH in Medicaid and beyond.

Read the highlights of our interview with Sara Ratner below or listen to the full conversation on episode 7 of Icario’s podcast RadioRev.

Let’s start with the basics. What are social determinants of health?

Social determinants of health are barriers to getting access to certain services, like healthcare. They can be a myriad of things like education, job opportunities, job training, transportation, social support, living in a high crime neighborhood—the list goes on.

Why do SDoH matter with the Medicaid population?

80% of patient health is determined by social factors and typically these factors are more relevant to the Medicaid population. This matters greatly because research suggests that medical care accounts for only 10-20% of health outcomes, while the other 80-90% is attributable to environmental and socio-economic factors, as well as individual behaviors otherwise known as SDoH.

To put this into perspective, let’s look at some statistics: 1 in 5 Americans are on Medicaid right now, which equates to 76 million people—that’s enormous! And, 2 out of 3 of those people are on a managed Medicaid plan.

With the ACA expansion, this has obviously grown substantially and many more people who would not typically be eligible for Medicaid are now eligible. A couple of items that are relevant to SDoH and why this is an important topic is that 6 in 10 of those previously mentioned as eligible are working families. 8 in 10 are families with at least 1 worker. I want to put into perspective the amount of people that are now eligible for Medicaid, and share why the impact of these social determinants is absolutely critical.

Further, additional items to mention that have a direct correlation on health that you might not expect are:

  • Education reduces your risk of dying within the next year by 1.8%
  • Graduating from high school and spending some time in college reduces your risk of heart disease by more than 2% and for diabetes it’s slightly more than 1%
  • Patients with breast, prostate, colon, or lung cancer that were married account for up to 18% of survival disparities among men and 14% of women, largely due to SDoH

By laying all of this out, it helps create a picture of what the barriers are, what’s the significance, and what are the implications of these different factors and how people access healthcare.

What makes engaging Medicaid members different from other populations, given what you’ve said about SDoH so far?

The key is that 45% of those who are on Medicaid are children or youth under 19—an enormous population that can be targeted for different programs and services, but practically speaking, very hard to target them for a variety of social and legal reasons.

Access to technology is another big consideration. While some working poor have jobs and access to technology, others have state-sponsored data plans associated with their cell phones. This means they may have limited access and data caps, so being judicious about how they use their data is critical—they’re going to use it in a way that’s meaningful to them. This creates a barrier because if their data is shut off, they can’t find access to services that could help them.

These are just a few examples, but there are countless barriers that make it much more difficult to deal with social determinants with this population versus others.

Switching gears to HEDIS and state quality measures, what measures are emphasized with Medicaid?

It varies across states. That’s one of the frustrating items when you’re trying to cover this whole population across a business. Icario has focused on each state individually and has done an analysis of every state to understand the quality indicators that exist and the environment where those are developed. The quality indicators largely focus on HEDIS and on specific state performance improvement programs. I’ve seen a major focus on maternal health, hospital readmissions, and avoidable admissions, as well as asthma and upper respiratory treatment. This is a big one for Medicaid because housing conditions may result in lead exposure and other toxins that cause asthma.

Individual states also focus heavily on CAHPS surveys—they want to understand if the population receiving care is happy. If there’s a group of dissatisfied individuals with a health plan, the state needs to know that so they can go in and help or at the very least, encourage the health plan to remediate some of the noted issues.

Based on what you’ve seen, where are the gaps?

There are 2 key gaps—education and transportation. I’ll focus on education and why it’s increasingly problematic for a couple of reasons.

First, the state systems vary across states, counties, and even cities, so the graduation rates and admissions to college, and even the number of people going to college varies widely, which is largely dependent on socio-economic status.

Second, we all experience how difficult it is to pay for college. Even if your parents save and you save independently for college, it puts people in an untenable situation where they graduate with massive amounts of debt. Layering that onto individuals who are already experiencing financial difficulty or have problems accessing basic services leads to another factor in why education is so important.

In addition, there is a newfound investment in trades. This is helping all populations because people can go to trade school to become an electrician or carpenter where they learn not just the trade, but the business components that surround actually operating in that trade. Hopefully this type of investment will continue because it opens up larger opportunities in a structured way for people to enter the workforce.

Where do you see an opportunity to drive better outcomes with the Medicaid population?

There are several areas of opportunity. Adult dental services, vision services for adults, transportation, and GED coaching are all incredibly important.

Wellness incentives are a huge opportunity to drive outcomes so people can actually understand what they need to be doing in order to prevent rather than just address. As an industry we need to find better ways to encourage people to go in for preventive services that keep them out of the hospital as well as helping people adopt proactive tendencies when it comes to their health and the health of their families.