Medicaid Strategies for Addressing Social Determinants of Health: Considerations from State Leaders for Improving Oral and Overall Health

Upstream factors such as access to nutritious food, education, and transportation drive inequities in oral health and health outcomes. States are working to improve the oral and physical health of Medicaid enrollees and to reduce costs by addressing social determinants of health (SDOH) in their managed care medical and dental contracts. The National Academy for State Health Policy (NASHP) recently convened state leaders to discuss emerging opportunities for addressing SDOH related to oral health and ways to leverage existing SDOH efforts in medical delivery systems for dental delivery systems. Three key themes emerged from the discussion: integrating medical and dental systems to more effectively coordinate care and address patients’ social needs; working with and educating different provider types – including community health workers and dental staff – to address social determinants of oral health; and investing in communities to support programs that promote health equity.

Medical/Dental Integration

Experts agree that dental care is essential health care, and therefore oral health is an important part of overall health. State Medicaid programs deliver dental services through different models, including fee-for-service, carved-in managed care programs where states contract with managed care organizations (MCOs), carved-out managed care programs where states contract with a dental MCO or a third-party administrator, or a combination of these models. States shared that regardless of their dental delivery system, there is ample opportunity to better integrate their medical and dental systems. Closed loop referral systems, state managed care contracting requirements, and shared data/metrics are examples of tools for integration to better address SDOH.

• A closed loop referral system is an important care coordination tool that uses technology to track cross-sector referrals and services a patient receives. Data is shared with multiple providers, lends accountability for community-clinical referrals, and can be used to identify gaps in available services. Arizona Medicaid recently launched its Whole Person Care Initiative to address enrollees’ SDOH and will implement a closed loop referral system for providers, health plans, community-based organizations (CBOs), and community stakeholders. In February 2021, the state’s Health Information Exchange (Health Current) contracted with a technology provider to work with Arizona Medicaid, Health Current, and 2-1-1 Arizona on the referral system. Through the closed loop system, enrollees will be screened for social risk factors and referred to highly matched community resources.
• States can use managed care contracting requirements to integrate medical and dental services. In Oklahoma, the state’s request for proposals includes language requiring the medical MCO to share an enrollee’s health risk screening information with the dental plan to prevent duplication and coordinate care. Kansas’ managed care contract includes a service coordinator to connect enrollees to CBOs for social needs based on a health risk assessment.
• State officials also identified data sharing as a key tool for medical and dental integration. In Michigan, officials are using lessons learned from the state’s physical and behavioral health integration, specifically the use of shared metrics, to inform their medical and dental integration. Michigan is also exploring data sharing with health plans around emergency dental data, for a shared metric between MCOs in the future. Pennsylvania is working with its MCOs to collect quality data for various dental services and discussing the specifics of their initiatives during quarterly meetings to highlight which demographics are impacted the most. The next step is to then investigate the specific barriers for each defined population within different areas, acknowledging different SDOH. Other state officials also mentioned the need for a shared diagnostic language between medical and dental providers such as ICD-10 Z codes used to document SDOH data.

Oral Health Workforce

State leaders agree that a strong oral health workforce is necessary to address SDOH. The oral health workforce includes dentists, dental hygienists, community health workers (CHWs), and other providers that deliver oral health services or provide important referrals to dental services. The Institute of Medicine’s Advancing Oral Health in America report recommends the use of all professionals in oral health care and training for collaborative efforts between dental and medical staff, including the use of referrals. During the roundtable, state officials stressed the importance of dental staff who reflect the community and therefore understand the resources available for care coordination and referrals.

• State officials identified the need for staff trained in SDOH and community resources to best address enrollees’ social needs. For example, Nebraska’s dental contract requires staff to be trained on how SDOH affect members’ health and wellness. A NASHP 50-state scan of medical and dental contracts revealed that more medical MCOs require training for SDOH than dental MCOs. Therefore, integrating medical and dental care can also leverage medical MCO staff training in SDOH.
• CHWs, community members with public health training, promote health equity and can address SDOH, along with oral and overall health needs. CHWs have served communities in Michigan since 1960. Since 2016, Michigan has required Medicaid MCOs to have CHWs based on an enrollee ratio. The current contract requires at least 1 full time CHW for every 5,000 enrollees. CHWs are an integral part of the MI Care Team Health Home program for Medicaid enrollees with chronic conditions to identify community resources, coordinate and track referrals, and provide health education. CHW programs also illustrate connections between public health programs that generally oversee CHW training and regulation and Medicaid programs that can finance CHWs.
• Rhode Island Medicaid piloted a dental case management program with CHWs, social workers, and dental staff. The goal of the program was to increase utilization in dental services and remove barriers to service delivery. Dental case managers provided motivational interviewing, health literacy activities, care coordination, community outreach, education, and appointment reminders. These services were tracked using Current Dental Terminology (CDT) codes to monitor care and patient needs. In one Federally Qualified Health Center, a CHW worked part time on case management and was successful in reducing the dental clinic’s no-show rate.  In 2021, the dental case management program was included in the state’s approved 1115 Comprehensive Demonstration Waiver.

Community Partnerships and Investment  

State leaders also discussed the importance of community partnerships and shared examples of how their states incentivize health plans to invest in the community. State governments can support system-level changes to address SDOH, and managed care plans also can play a valuable role given their extensive reach, existing relationships with members, and larger budgets. However, CBOs and community members also play an important role in improving health equity; according to state leaders, it is critical to ensure that community members are actively engaged in addressing SDOH and that the relationship between the plan and the community is bidirectional. Through their Medicaid medical and dental contracts, some states have started requiring MCOs to support the work of CBOs to improve residents’ social and economic needs. States might consider encouraging dental plans and providers to make similar investments in SDOH and community partnerships to address health equity:

• Arizona’s Medicaid MCO contracts require the plans to spend at least 6 percent of their annual profits on community reinvestment, with a special focus on SDOH. In 2020, the MCOs pooled a portion of their community reinvestment dollars to invest in Home Matters to Arizona, a statewide initiative to improve access to affordable housing. The MCOs’ grants helped create the $100 million Home Matters Arizona Fund to finance affordable housing projects and development. These new funds will prioritize investment in CBO development of affordable housing to serve Medicaid-eligible and other low-income households throughout Arizona. Especially in a state like Arizona, where the dental benefit is carved into the medical managed care program, the dental program and dental subcontractors could work with medical plans or with each other to pool profits and reinvest in the community to maximize impact.
• Similarly, Rhode Island’s Accountable Entities (AEs) must allocate 10 percent of the incentive funds they earn to CBOs that support behavioral health care, substance abuse treatment and/or SDOH. The state encourages AEs to use these funds to build CBO capacity – including supporting their technological, analytical, and care coordination needs –to integrate health and social services and help the CBOs enter into financial arrangements with health systems. By requiring the health plans to invest in community partners, Rhode Island aims to strengthen the link between clinical and community settings.

In addition to the medical system efforts, some states also require dental plans to partner with CBOs:

• Nevada requires its dental vendor to use annual community-based needs assessments to evaluate the health education, cultural, and linguistic needs of the plan’s members. The vendor must then implement culturally appropriate health promotion and education activities to address any identified needs.
• In Nebraska, the dental contractor employs Member Advocate and Outreach Specialists, who partner with CBOs to help educate members about their dental benefits and connect individuals to community resources.

Strong partnerships between health systems and CBOs are necessary to address SDOH and make lasting change. It can be challenging, though, to bring together stakeholders with different resources, budgets, and terminologies. State officials identified multiple keys to success for these relationships, including establishing clear responsibilities through an MOU, acknowledging the different organizations’ operating budgets, compensating CBOs for their work, and making sure that representatives from the medical and dental systems and from CBOs use a shared language and are familiar with each other’s terminology.

Conclusion 

Evidence suggests that addressing SDOH improves physical and oral health outcomes. In both medical and dental delivery systems, states are finding innovative ways to address individuals’ and communities’ social and economic needs to improve health. Many of these initiatives are currently driven by the medical system, but they can also serve as examples of programs and contract language that states might consider adopting for dental plans.

Though conversations about health equity often focus on Medicaid’s role in driving SDOH-related initiatives, public health agencies and providers are key players and may have best practices for improving population health from which Medicaid can learn. Contractual requirements and incentive payments may motivate medical and dental plans to address SDOH, but Medicaid MCOs tend to focus their initiatives on their own membership. Encouraging Medicaid to address population-wide concerns remains a challenge, likely in part due to how Medicaid is funded and federal limits on how dollars may be used. Arizona’s Medicaid MCOs’ joint investment in housing is one example of how Medicaid can support community-level initiatives statewide. NASHP will continue to bring together state Medicaid and public health medical and dental leaders to discuss best practices and strategies for addressing SDOH as they relate to oral and overall health.

This blog and the related activities were made possible by support from the CareQuest Institute for Oral Health. The authors would like to thank the CareQuest Institute and the state officials who helped review and provide feedback on this blog.