Social Determinant Needs Greater Among Medicare Advantage Patients

Hospices gearing up for a Medicare Advantage carve-in demonstration in 2021 may place greater emphasis on addressing social determinants of health, as Medicare Advantage beneficiaries are increasingly affected by a lack of associated services, according to a report from consulting firm Avalere Health. Patients with dual eligibility for Medicare and Medicaid are the most affected, according to the report.

Social determinants of health include patient and family demographics, access to and quality of housing, food, and transportation, as well as internet access and other socio-economic factors.

“Information on social determinants of health will be essential for strategic planning of services and providing the appropriate end-of-life care,” said Christie Teigland, researcher with Inovalon Inc., and author of the report. “Factors such as living below the federal poverty level, low education status, lack of family or social supports, loneliness, and other social risk issues will need to be addressed to achieve the best overall care experience for these patients.”


Hospices are uniquely positioned to address social determinants, as most providers consider this a part of their mission, essential to maintaining patients’ quality of life during their final days.

“Hospice has always been a population health kind of model. This is one of the original great innovations from the very inception of the benefit,” National Association for Home Health and Hospice President William Dombi told Hospice News. “Hospices already look at social determinants. They look at the family factor, housing, nutrition, and how the overall environment affects patient care.”

The health care industry at large, as well as payors and regulators, are beginning to pay increased attention to social determinants.


Last month, the U.S. Centers for Medicare & Medicaid Services (CMS) announced that it would begin providing supplemental non-primarily health-related benefits for certain Medicare Advantage beneficiaries based on the patient’s specific medical condition and needs. These benefits include a range of services from providing meals to installing air purifiers or cleaning carpeting in the homes of patients with asthma.

As of 2018, more than 20 million people were enrolled in Medicare Advantage, representing 34% of Medicare beneficiaries.

Insurance giant Humana, which operates hospice provider Kindred Healthcare, is working to expand programs to address supplemental benefits, Home Health Care News recently reported. United Healthcare recently collaborated with the American Medical Association to create billing codes that clinicians can use to process claims related to social determinants.

For its report, Avalere examined 2015 Medicare Advantage claims and ZIP code data for more than 1.8 million beneficiaries, finding that more than 50% of patients with full dual eligibility dwell in locales with a median income of less than $30,000, with more than half living in an area where as many as 20% of households are below the federal poverty line.

Dual-eligible patients were more likely that non-dual beneficiaries to be young, female, disabled, members of racial or ethnic minorities, and predominantly live in urban areas.They are also more likely to be high-acuity patients: 2.4 times more likely to suffer from Alzheimer’s disease, and between 1.5 and 2 times more likely to suffer from heart failure, and stroke, Avalere reported.

Though hospice utilization among patients with those conditions is growing, dual eligible patients are more likely than non-dual eligible patients pursue more costly forms of care such as emergency department visits and hospitalizations. Overall health care costs for dual eligible patients are 70% higher than those of non-dual eligible patients, Avalere found.

In 2016, cardiac and circulatory conditions were the second most common diagnoses among hospice decedents, representing 18.7%. Dementia patients followed close behind at 18%, with 9.5% of decedents having stroke as a primary diagnosis according to the National Hospice and Palliative Care Organization.

With most hospices having systems in place for addressing some non-medical needs, they have an opportunity to capitalize on new reimbursement opportunities when they are carved into Medicare Advantage, whether they provide the services directly or partner with other community organizations.

“There are ways to invest in that at the mid market,” Bill Frist, former U.S. Senate Majority Leader and current partner in health care investment firm Frist-Cressey Ventures, told Hospice News. “The way for hospice and palliative care organizations to accelerate that is to find a business model—really a sustainable resource model— that allows the provider to seamlessly link an individual patient and their needs, as interpreted by the patient and family, to resources in the community. I believe that over the next three years that model will evolve.”

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