Minnesota Department of Human Services | mn.gov/dhs Social Determinants of Health in MN APMs Marie Zimmerman, Medicaid Director Minnesota Department of Human Services | mn.gov/dhs

Medicaid Tomorrow A drive toward whole-person care, lower-cost and better health outcomes + The acknowledgement that provider reach is only so deep, housing, income, justice-involved, food security are unaddressed = A desire to integrate the health care system and social services -Shift in focus on needs of the "whole person" versus just trying to manage care and cost through networks and benefit limits. Particularly for low-income populations who often have complex lives due to temporary or chronic poverty. -Payers, like Medicaid, changing health care provider financial incentives from pay just for discrete procedures to paying for achieving lower costs and better health outcomes -Health care providers understanding that only so much they can influence within health care system factors outside health care services - employment, income, food security, housing, transportation, criminal justice involvement, etc - impact a persons health (and costs) and their ability to achieve well being = social determinants of health

Coordinating Care, Through New Provider Incentives Health care providers work together across specialties and service settings to meet patient needs. These providers share in savings they help create and in losses when goals are not met. They look for innovations to improve the health of their communities. Paying for value and good health outcomes instead of the number of visits or procedures.

Integrated Health Partnerships (IHPs) $213 million in savings 14 percent drop in expensive hospital stays 460,00 people served

Hennepin Health Partnerships: Homelessness/Employment MN - has been going in this direction of paying for value and trying to provider greater flexibility in how to use that funding to pay for non-medical services that improve health and lower cost -SHH work under SIM with direct funding, instead payments thru health care providers -hcmc, harbor lights, vocational rehab for adults with smi  

Collaboration between IHPs and Food Banks  -food as medicine and as way to manage and improve chronic condition (Food Rx) -Food insecurity maybe be “easier” to tackle for relative to other SDOH like the availability of affordable housing. -capitalizing on existing access points for the delivery of food, the more people have to come back the more they fail – “non-compliance” Shared mission and population + strong collaborations = improved health

Moving forward quality, IHP 2 Relevant, partnerships and measurable quality improvement activity Population- Based Payment Social Risk Factors Quality – Using research with Medical Director’s office to get an understanding of 1) social risk factors in the children and adult Medicaid population that impact health outcomes, 2) discuss with IHPs what they are doing to address these populations 3) requiring them to propose a measure that is actionable and representative of their efforts to address these population health issues.   Eligibility to receive the population-based payment is tied to an IHP’s ability to evaluate, intervene, and improve the health of its attributed patients. The IHP will work with DHS to agree on quality, health equity, and utilization measures to evaluate the effectiveness of efforts by the IHP to improve the health outcomes of its attributed population. During contract discussions, the IHP attributed population will be examined to determine its predominant health disparities using DHS data as well as information provided by the IHP. The IHP will be required to propose a health equity measure(s) tied to interventions that are intended to reduce health disparities among the IHP’s population. The IHP will be annually evaluated on the set of agreed upon measures to determine its progress on quality improvement. A lack of improvement or an insufficient quality performance could result in modifications or discontinuation of the population-based payment after the conclusion of an IHP’s three-year contract cycle. 1/09/2017

Moving forward payment reform, IHP 2.0 Social determinants of health risk factors are an adjustment to the PBP amount The population-based payment includes both a clinical risk adjustment as well as a SDoH adjustment Social factors act as up weight within the ACG group for patients experiencing those specific factors A provider selected quality improvement project to address SDoH and health disparities is required. Greater level of shared savings if system includes partnerships outside it’s medical system.

Moving forward payment reform, IHP 2.0 Risk Factors Adult Population Children Deep poverty Homelessness SPMI Parental SPMI SUD Parental SUD Prison History Parental Prison History   Child Protection Involvement Need to balance the goals of meaningful payment level, while avoiding risks of payment level overly impacting performance PBP is not optional or variable based on IHP preference On the other hand, it is not “one size fits all” – different IHPs will receive different payment levels, based on the characteristics of their attributed populations It is not reasonable to expect that the characteristics driving differential care need are consistent across the populations of the IHPs Payment level should reasonably vary by IHP based on the relative number of high- and low-risk attributed members in the IHP Payment level will vary based on the populations’ relative medical risk Payment level will also vary based on the populations' social determinants of health The baseline PBP should be considered an average across the entire population Average payment rate for top 10% or risk is around $10.00-15.00 or 4-5X the payment rate for the population with lower-than-average medical risk (Pending SDH decisions) Although per member payment level used to calculate the average PBP can vary considerably, the average PBP is only expected to vary 10-20% between IHPs (Pending payment rate finalization)

Challenges to consider Health Care Providers Social Service Orgs Accountability Carry the burden for making the business case New to risk Don’t understand how social services are delivered Challenges: -Health care providers don't get how these services are delivered and what the access points – TOO MANY access points They are managing a changing landscape of how their revenue is shifting, may be less willing to invest in early years, looking for quick, short term savings   The burden is often on the social service agencies to make the business case and develop the model, and often finance the start up Long-term financial sustainability is unclear, but need to get away from grants Top SDOH factors have not been determined for Medicaid population - both good and bad -Social services agencies often want funding without being accountable outcomes – still under grant mindset versus reward and risk financial incentives. Health care providers are being held to downside financial risk – Are You Ready to be at Risk? 11/6/2018 Minnesota Department of Human Services | mn.gov/dhs

Thank you Marie Zimmerman Medicaid Director 651-431-4233 Marie.Zimmerman@state.mn.us